Healthcare disparities: patients' perspectives on barriers to joint replacement.

OBJECTIVE: Racial and ethnic disparities in arthroplasty utilization are evident, but the reasons are not known. We aimed to identify concerns that may contribute to barriers to arthroplasty from the patient's perspective. METHODS: We identified patients' concerns about arthroplasty by performing a mixed methods study. Themes identified during semi-structured interviews with Black and Hispanic patients with advanced symptomatic hip or knee arthritis were used to develop a questionnaire to quantify and prioritize their concerns. Multiple linear and logistic regression analyses were conducted to determine the association between race/ethnicity and the importance of each theme. Models were adjusted for sex, insurance, education, HOOS, JR/KOOS, JR, and discussion of joint replacement with a doctor. RESULTS: Interviews with eight participants reached saturation and provided five themes used to develop a survey answered by 738 (24%) participants; 75.5% White, 10.3% Black, 8.7% Hispanic, 3.9% Asian/Other. Responses were significantly different between groups (p < 0.05). Themes identified were "Trust in the surgeon" "Recovery", "Cost/Insurance", "Surgical outcome", and "Personal suitability/timing". Compared to Whites, Blacks were two-fold, Hispanics four-fold more likely to rate "Trust in the surgeon" as very/extremely important. Blacks were almost three times and Hispanics over six times more likely to rate "Recovery" as very/extremely important. CONCLUSION: We identified factors of importance to patients that may contribute to barriers to arthroplasty, with marked differences between Blacks, Hispanics, and Whites.

A single-center, open-label, randomized, parallel-group trial to pilot the effectiveness of a peer coach behavioral intervention versus an active control in reducing anxiety and depression in patients scheduled for total knee replacement.

BACKGROUND: Moving Well is a behavioral intervention for patients with knee osteoarthritis (KOA) scheduled for a total knee replacement (TKR). The objective of this intervention is to help patients with KOA mentally and physically prepare for and recover from TKR. METHODS: This is an open-label pilot randomized clinical trial that will test the feasibility and effectiveness of the Moving Well intervention compared to an attention control group, Staying Well, to reduce symptoms of anxiety and depression in patients with KOA undergoing TKR. The Moving Well intervention is guided by Social Cognitive Theory. During this 12-week intervention, participants will receive 7 weekly calls before surgery and 5 weekly calls after surgery from a peer coach. During these calls, participants will be coached to use principles of cognitive behavioral therapy (CBT), stress reduction techniques, and will be assigned an online exercise program, and self-monitoring activities to complete on their own time throughout the program. Staying Well participants will receive weekly calls of similar duration from research staff to discuss a variety of health topics unrelated to TKR, CBT, or exercise. The primary outcome is the difference in levels of anxiety and/or depression between participants in the Moving Well and Staying Well groups 6 months after TKR. DISCUSSION: This study will pilot test the feasibility and effectiveness of Moving Well, a peer coach intervention, alongside principles of CBT and home exercise, to help patients with KOA mentally and physically prepare for and recover from TKR. TRIAL REGISTRATION: Clinicaltrials.gov. NCT05217420; Registered: January 31, 2022.

Protocol for the pilot randomized trial of the CArdiovascular Risk assEssment for Rheumatoid Arthritis (CARE RA) intervention: a peer coach behavioral intervention.

BACKGROUND: Cardiovascular disease (CVD) is the most common cause of death among people with rheumatoid arthritis (RA), with an estimated increased risk of 50-60% compared to the general population. Lipid-lowering strategies have been shown to lower CVD risk significantly in people with RA and hyperlipidemia. Thus, CVD risk assessment has an important role to play in reducing CVD among people with RA. Yet currently only 37 to 45% of this population are receiving primary lipids screening. This paper describes the CArdiovascular Risk assEssment for RA (CARE RA) intervention, which is designed to address this issue. CARE RA is a peer coach intervention, that is, an intervention in which a person with RA coaches another person with RA, which is designed to educate people with RA about the relation between RA and CVD risk and to help them obtain evidence-based CVD risk assessment and treatment. METHODS: This is an open-label pilot study that will test if the participants assigned to complete the CARE RA curriculum with a peer coach will receive a cardiovascular risk assessment more frequently compared to those that complete the CARE RA curriculum by themselves. The CARE RA intervention is guided by Social Cognitive Theory. Participants in the peer coach intervention arm will receive the assistance of a peer coach who will call the participants once a week for 5 weeks to go over the CARE RA curriculum and train them on how to obtain CVD risk assessment. The control arm will complete the CARE RA curriculum without any assistance. Participants will be randomized 1:1 either to the control arm or to the peer coach intervention arm. The primary outcome is a participant's having a CVD risk assessment or initiating a statin, if indicated. Secondary outcomes include patient activation and RA medication adherence. The RE-AIM implementation framework guides the implementation and evaluation of the intervention. DISCUSSION: This pilot study will test the feasibility of the peer coach intervention in anticipation of a larger trial. CARE RA pioneers the use of peer coaches to facilitate the implementation of evidence-based treatment guidelines among people with RA. TRIAL REGISTRATION: ClinicalTrials.gov NCT04488497 . Registered on July 28, 2020.

Prevalence of Frailty in Ankylosing Spondylitis, Psoriatic Arthritis, and Rheumatoid Arthritis: Data from a National Claims Dataset.

OBJECTIVE: Frailty is associated with disability and mortality independent of age. Although studies have evaluated frailty in rheumatoid arthritis (RA), information on the prevalence of frailty in ankylosing spondylitis (AS) and psoriatic arthritis (PsA) is limited. We aimed to determine the prevalence of frailty in AS and PsA and to evaluate whether characteristics known to be associated with frailty, including anxiety, differ among these three types of inflammatory arthritis. METHODS: We performed a cross sectional study of Centers for Medicare & Medicaid Services (CMS) beneficiaries aged 65 years or older with AS, PsA, or RA enrolled in 2014. We operationalized frailty using a validated claims-based frailty index. We also explored the prevalence of frailty among CMS beneficiaries younger than age 65 years with work disability, a younger population that also may be at risk of frailty. RESULTS: The prevalence of frailty in beneficiaries aged 65 years or older with AS and PsA was 45.2% and 46.7%, respectively, significantly lower than in RA (65.9%, P < 0.05). The prevalence of frailty in beneficiaries less than 65 years old was much lower overall, though still highest in RA; 11.7%, 4.4%, and 7.0% in RA, AS, and PsA, respectively (P < 0.05). Anxiety was significantly associated with frailty in subjects of all ages, particularly among those less than 65 years old (P < 0.05). CONCLUSION: Almost half of beneficiaries with AS or PsA aged 65 years old or older were frail, higher than in younger disabled beneficiaries. Further studies are needed to understand the risks of developing frailty in these diseases. Frailty was associated with anxiety, particularly in the younger age groups.

Association of cardiovascular disease and traditional cardiovascular risk factors with the incidence of dementia among patients with rheumatoid arthritis.

OBJECTIVE: To determine the incidence of dementia in patients with rheumatoid arthritis (RA) 65 years and older, and compare the incidence of dementia in patients with RA with prevalent cardiovascular (CV) disease (CVD), CV risk factors but no prevalent CVD and neither (referent group). METHODS: We analyzed claims data from the Center for Medicare & Medicaid Services (CMS) from 2006-2014. Eligibility criteria included continuous medical and pharmacy coverage for ≥ 12 months (baseline period 2006), > 2 RA diagnoses by a rheumatologist and at least 1 medication for RA. CVD and CV risk factors were identified using codes from the Chronic Condition Data Warehouse. Incident dementia was defined by 1 inpatient or 2 outpatient claims, or one dementia specific medication. Age-adjusted incident rates were calculated within each age strata. Univariate and multivariate Cox proportional hazard models were used to calculate Hazard Ratios (HR) and 95% confidence intervals. RESULTS: Among 56,567 patients with RA, 11,789 (20.1%) incident cases of dementia were included in the main analysis. Age adjusted incident rates were high among all groups and increased with age. After adjustment for age, sex, comorbidities and baseline CV and RA medications, patients with CVD and CV risk factors between 65 and 74 years had an increased risk for incident dementia compared to those without CVD and without CV risk factors (HR 1.18 (95% CI 1.04-1.33) and HR 1.03 (95% CI 1.00-1.11), respectively). We observed a trend towards increased risk in patients between 75 and 84 years with CVD at baseline. CONCLUSION: Patients with RA with both CVD and CV risk factors alone are at an increased risk for dementia compared to those with neither CVD nor CV risk factors; however, this risk is attenuated with increasing age. The impact of RA treatment and CV primary prevention strategies in the prevention of dementia in patients with RA warrants further studies.

Racial and ethnic differences in medication use among beneficiaries of social security disability insurance with rheumatoid arthritis.

OBJECTIVE: To determine racial/ethnic differences in the use of conventional synthetic or biologic disease-modifying anti-rheumatic drugs (csDMARDs or bDMARDs, respectively) and long-term glucocorticoids (GC) or opioids among beneficiaries of the Social Security Disability Insurance (SSDI) with rheumatoid arthritis (RA) and <65 years old. METHODS: Serial cross-sectional analyses of Centers for Medicare and Medicaid Services claims data (2007, 2011, and 2014) for individuals <65 years old with RA receiving SSDI Medicare and Medicaid, no longer working because they were considered disabled. Generalized estimating equation models were used to determine whether the proportion of patients who used csDMARD, bDMARD, long-term GC, and long-term opioids differed by race/ethnicity. RESULTS: There were 12,931; 15,033; and 15,599 participants in 2007, 2011, and 2014, respectively. The overall use of csDMARD without bDMARD among beneficiaries of the SSDI were 31.1%, 30.3%, and 29.2%; 50.2%, 51.7%, and 53.8% used bDMARDs; 37.6%, 36.1%, and 34.4% used long-term GC; and 61.1%, 63.8%, and 63.7% used long-term opioids in years 2007, 2011, and 2014 respectively. The use of csDMARDs without bDMARDs was higher and the use of bDMARDs was lower among Blacks compared to Whites (adjusted absolute difference: +3.0%, +5.0%, and +3.3% for csDMARDs without bDMARDs and -4.6%, -5.7%, and -4.0% for bDMARDs in 2007, 2011, and 2014, respectively; all p<0.05). The use of bDMARDs was higher among Hispanics compared to Whites (adjusted absolute difference: +7.1%, +7.3%, and +7.5% in 2007, 2011, and 2014, respectively; all p<0.05). Long-term GC use was lower among Hispanics than among Whites only in year 2014 (absolute percentage point difference of -4.2%); no other difference in long-term GC use was identified. Whites were the patients with the highest use of long-term opioids (more than two third in each calendar year). CONCLUSION: Racial and ethnic differences exists in regards to the treatment of RA among beneficiaries of the SSDI. These findings suggest that this already vulnerable population of patients with RA can also have a racial and ethnic disparity that can contribute to additional disease burden and that should be examined in order to inform future interventions or even inform future policy changes to the SSDI.

Views of primary care physicians and rheumatologists regarding screening and treatment of hyperlipidemia among patients with rheumatoid arthritis.

BACKGROUND: Despite high risk for cardiovascular disease (CVD) mortality, screening and treatment of hyperlipidemia in patients with rheumatoid arthritis (RA) is suboptimal. We asked primary care physicians (PCPs) and rheumatologists to identify barriers to screening and treatment for hyperlipidemia among patients with RA. METHODS: We recruited rheumatologists and PCPs nationally to participate in separate moderated structured group teleconference discussions using the nominal group technique. Participants in each group generated lists of barriers to screening and treatment for hyperlipidemia in patients with RA, then each selected the three most important barriers from this list. The resulting barriers were organized into physician-, patient- and system-level barriers, informed by the socioecological framework. RESULTS: Twenty-seven rheumatologists participated in a total of 3 groups (group size ranged from 7 to 11) and twenty PCPs participated in a total of 3 groups (group size ranged from 4 to 9). Rheumatologists prioritized physician level barriers (e.g. 'ownership' of hyperlipidemia screening and treatment), whereas PCPs prioritized patient-level barriers (e.g. complexity of RA and its treatments). CONCLUSION: Rheumatologists were conflicted about whether treatment of CVD risk among patients with RA should fall within the role of the rheumatologist or the PCP. All participating PCPs agreed that CVD risk reduction was within their role. Factors that influenced PCPs' decisions for screening and treatment for CVD risk in patients with RA were mainly related to their concern about how treatment for CVD risk could influence RA symptomatology (myalgia from statins) or how inflammation from RA and RA medications influences lipid profiles.