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Raffaele Scarpa - One of the best experts on this subject based on the ideXlab platform.
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red flags for appropriate referral to the gastroenterologist and the Rheumatologist of patients with inflammatory bowel disease and spondyloarthritis
Clinical and Experimental Immunology, 2019Co-Authors: Carla Felice, Pietro Leccese, Luigia Scudeller, E Lubrano, Fabrizio Cantini, F Castiglione, Paolo Gionchetti, A Orlando, Carlo Salvarani, Raffaele ScarpaAbstract:Collaboration between gastroenterologists and Rheumatologists is recommended for the correct management of patients with associated spondyloarthritis (SpA) and inflammatory bowel disease (IBD). We aimed to establish the appropriateness of several red flags for a prompt specialist referral. A systematic review of the literature was performed using the GRADE method to describe the prevalence of co-existing IBD-SpA and the diagnostic accuracy of red flags proposed by a steering committee. Then, a consensus among expert gastroenterologists and Rheumatologists (10 in the steering committee and 13 in the expert panel) was obtained using the RAND method to confirm the appropriateness of each red flag as 'major' (one sufficient for patient referral) or 'minor' (at least three needed for patient referral) criteria for specialist referral. The review of the literature confirmed the high prevalence of co-existing IBD-SpA. Positive and negative predictive values of red flags were not calculated, given the lack of available data. A consensus among gastroenterology and rheumatology specialists was used to confirm the appropriateness of each red flag. Major criteria to refer patients with SpA to the gastroenterologist included: rectal bleeding, chronic abdominal pain, perianal fistula or abscess, chronic diarrhoea and nocturnal symptoms. Major criteria to refer patients with IBD to the Rheumatologist included: chronic low back pain, dactylitis, enthesitis and pain/swelling of peripheral joints. Several major and minor red flags have been identified for the diagnosis of co-existing IBD-SpA. The use of red flags in routine clinical practice may avoid diagnostic delay and reduce clinic overload.
Daniel H Solomon - One of the best experts on this subject based on the ideXlab platform.
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comparison of care provided in practices with nurse practitioners and physician assistants versus subspecialist physicians only a cohort study of rheumatoid arthritis
Arthritis Care and Research, 2015Co-Authors: Daniel H Solomon, Liana Fraenkel, Erika M Brown, Peter Tsao, Elena Losina, Jeffrey N Katz, Asaf BittonAbstract:Objective The Affordable Care Act proposes wider use of nurse practitioners (NPs) and physician assistants (PAs), but little is known about outcomes of care provided by them in medical specialties. We compared the outcomes of care for patients with rheumatoid arthritis (RA) seen in practices with NPs or PAs and Rheumatologists versus practices with Rheumatologists only. Methods We enrolled 7 rheumatology practices in the US (4 with NPs or PAs and 3 without). RA disease activity (categorized as in remission, low, moderate, or high, using standardized measures) was abstracted from medical records from the most recent 2 years. We performed a repeated-measures analysis using generalized linear regression to compare disease activity for visits to practices with NPs or PAs versus Rheumatologist-only practices, adjusting for disease duration, serologic status, RA treatments, and disease activity measures. Results Records from 301 patients, representing 1,982 visits, were reviewed. The patients’ mean age was 61 years and 77% were female. In the primary adjusted analysis, patients seen in practices with NPs or PAs were less likely to have higher disease activity (odds ratio 0.32, 95% confidence interval 0.17–0.60; P = 0.004) than those seen in Rheumatologist-only practices. However, there were no differences in the change in disease activity. Conclusion Patients seen in practices with NPs or PAs had lower RA disease activity over 2 years compared to those seen in Rheumatologist-only practices; no differences were observed in the change in disease activity between visits either within or between the different types of provider practice.
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use of disease modifying medications for rheumatoid arthritis by race and ethnicity in the national ambulatory medical care survey
Arthritis Care and Research, 2012Co-Authors: Daniel H Solomon, Edward H Yelin, John Z Ayanian, Tamara Shaykevich, Alan M Brookhart, Jeffrey N KatzAbstract:Objective Disease-modifying antirheumatic drugs (DMARDs) are recommended for virtually all patients with rheumatoid arthritis (RA). We investigated the use of DMARDs in patients with RA in a nationally representative sample of visits to US physicians in the National Ambulatory Care Medical Survey (NAMCS). Methods We analyzed the NAMCS visit data from 1996 through 2007 if the physician noted a diagnosis of RA. DMARD utilization was based on the medications listed by the physician. We used generalized linear models to examine the adjusted associations between DMARD use and potential predictors. Results Of the 859 visits with a diagnosis code of RA identified over the study period, 404 visits (47%; 95% confidence interval [95% CI] 44–50%) had an associated DMARD. The percentage of RA visits with DMARDs increased slightly over the 12 years (P = 0.048), with biologic DMARDs increasing to 20% of visits after their introduction (P for trend <0.001). In fully adjusted models, African American race was associated with a 30% reduction in DMARD prescribing (risk ratio [RR] 0.70, 95% CI 0.48–1.00). A visit to a Rheumatologist was the strongest correlate of DMARD prescribing (RR 2.33, 95% CI 1.89–2.86). Among visits to nonRheumatologists, African Americans were significantly less likely than whites to receive a DMARD (RR 0.39, 95% CI 0.17–0.92), but not among visits with Rheumatologists (RR 0.81, 95% CI 0.52–1.27). Conclusion In the NAMCS, most visits coded with RA did not have an associated DMARD prescription. African Americans were less likely to receive DMARDs than whites, particularly when visiting nonRheumatologists.
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validation of rheumatoid arthritis diagnoses in health care utilization data
Arthritis Research & Therapy, 2011Co-Authors: Seoyoung C Kim, Jeffrey N Katz, Amber Servi, Jennifer M Polinski, Helen Mogun, Michael E Weinblatt, Daniel H SolomonAbstract:Introduction: Health care utilization databases have been increasingly used for studies of rheumatoid arthritis (RA). However, the accuracy of RA diagnoses in these data has been inconsistent. Methods: Using medical records and a standardized abstraction form, we examined the positive predictive value (PPV) of several algorithms to define RA diagnosis using claims data: A) at least two visits coded for RA (ICD-9, 714); B) at least three visits coded for RA; and C) at least two visits to a Rheumatologist for RA. We also calculated the PPVs for the subgroups identified by these algorithms combined with pharmacy claims data for at least one disease-modifying anti-rheumatic drug (DMARD) prescription. Results: We invited 9,482 Medicare beneficiaries with pharmacy benefits in Pennsylvania to participate; 2% responded and consented for review of their medical records. There was no difference in characteristics between respondents and non-respondents. Using ‘RA diagnosis per Rheumatologists’ as the gold standard, the PPVs were 55.7% for at least two claims coded for RA, 65.5% for at least three claims for RA, and 66.7% for at least two rheumatology claims for RA. The PPVs of these algorithms in patients with at least one DMARD prescription increased to 86.2%-88.9%. When fulfillment of 4 or more of the ACR RA criteria was used as the gold standard, the PPVs of the algorithms combined with at least one DMARD prescriptions were 55.6%-60.7%.
Jeffrey N Katz - One of the best experts on this subject based on the ideXlab platform.
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comparison of care provided in practices with nurse practitioners and physician assistants versus subspecialist physicians only a cohort study of rheumatoid arthritis
Arthritis Care and Research, 2015Co-Authors: Daniel H Solomon, Liana Fraenkel, Erika M Brown, Peter Tsao, Elena Losina, Jeffrey N Katz, Asaf BittonAbstract:Objective The Affordable Care Act proposes wider use of nurse practitioners (NPs) and physician assistants (PAs), but little is known about outcomes of care provided by them in medical specialties. We compared the outcomes of care for patients with rheumatoid arthritis (RA) seen in practices with NPs or PAs and Rheumatologists versus practices with Rheumatologists only. Methods We enrolled 7 rheumatology practices in the US (4 with NPs or PAs and 3 without). RA disease activity (categorized as in remission, low, moderate, or high, using standardized measures) was abstracted from medical records from the most recent 2 years. We performed a repeated-measures analysis using generalized linear regression to compare disease activity for visits to practices with NPs or PAs versus Rheumatologist-only practices, adjusting for disease duration, serologic status, RA treatments, and disease activity measures. Results Records from 301 patients, representing 1,982 visits, were reviewed. The patients’ mean age was 61 years and 77% were female. In the primary adjusted analysis, patients seen in practices with NPs or PAs were less likely to have higher disease activity (odds ratio 0.32, 95% confidence interval 0.17–0.60; P = 0.004) than those seen in Rheumatologist-only practices. However, there were no differences in the change in disease activity. Conclusion Patients seen in practices with NPs or PAs had lower RA disease activity over 2 years compared to those seen in Rheumatologist-only practices; no differences were observed in the change in disease activity between visits either within or between the different types of provider practice.
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use of disease modifying medications for rheumatoid arthritis by race and ethnicity in the national ambulatory medical care survey
Arthritis Care and Research, 2012Co-Authors: Daniel H Solomon, Edward H Yelin, John Z Ayanian, Tamara Shaykevich, Alan M Brookhart, Jeffrey N KatzAbstract:Objective Disease-modifying antirheumatic drugs (DMARDs) are recommended for virtually all patients with rheumatoid arthritis (RA). We investigated the use of DMARDs in patients with RA in a nationally representative sample of visits to US physicians in the National Ambulatory Care Medical Survey (NAMCS). Methods We analyzed the NAMCS visit data from 1996 through 2007 if the physician noted a diagnosis of RA. DMARD utilization was based on the medications listed by the physician. We used generalized linear models to examine the adjusted associations between DMARD use and potential predictors. Results Of the 859 visits with a diagnosis code of RA identified over the study period, 404 visits (47%; 95% confidence interval [95% CI] 44–50%) had an associated DMARD. The percentage of RA visits with DMARDs increased slightly over the 12 years (P = 0.048), with biologic DMARDs increasing to 20% of visits after their introduction (P for trend <0.001). In fully adjusted models, African American race was associated with a 30% reduction in DMARD prescribing (risk ratio [RR] 0.70, 95% CI 0.48–1.00). A visit to a Rheumatologist was the strongest correlate of DMARD prescribing (RR 2.33, 95% CI 1.89–2.86). Among visits to nonRheumatologists, African Americans were significantly less likely than whites to receive a DMARD (RR 0.39, 95% CI 0.17–0.92), but not among visits with Rheumatologists (RR 0.81, 95% CI 0.52–1.27). Conclusion In the NAMCS, most visits coded with RA did not have an associated DMARD prescription. African Americans were less likely to receive DMARDs than whites, particularly when visiting nonRheumatologists.
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validation of rheumatoid arthritis diagnoses in health care utilization data
Arthritis Research & Therapy, 2011Co-Authors: Seoyoung C Kim, Jeffrey N Katz, Amber Servi, Jennifer M Polinski, Helen Mogun, Michael E Weinblatt, Daniel H SolomonAbstract:Introduction: Health care utilization databases have been increasingly used for studies of rheumatoid arthritis (RA). However, the accuracy of RA diagnoses in these data has been inconsistent. Methods: Using medical records and a standardized abstraction form, we examined the positive predictive value (PPV) of several algorithms to define RA diagnosis using claims data: A) at least two visits coded for RA (ICD-9, 714); B) at least three visits coded for RA; and C) at least two visits to a Rheumatologist for RA. We also calculated the PPVs for the subgroups identified by these algorithms combined with pharmacy claims data for at least one disease-modifying anti-rheumatic drug (DMARD) prescription. Results: We invited 9,482 Medicare beneficiaries with pharmacy benefits in Pennsylvania to participate; 2% responded and consented for review of their medical records. There was no difference in characteristics between respondents and non-respondents. Using ‘RA diagnosis per Rheumatologists’ as the gold standard, the PPVs were 55.7% for at least two claims coded for RA, 65.5% for at least three claims for RA, and 66.7% for at least two rheumatology claims for RA. The PPVs of these algorithms in patients with at least one DMARD prescription increased to 86.2%-88.9%. When fulfillment of 4 or more of the ACR RA criteria was used as the gold standard, the PPVs of the algorithms combined with at least one DMARD prescriptions were 55.6%-60.7%.
Angela Zink - One of the best experts on this subject based on the ideXlab platform.
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Patients with rheumatoid arthritis facing sick leave or work disability meet varying regulations: a study among Rheumatologists and patients from 44 European countries
Annals of the Rheumatic Diseases, 2019Co-Authors: Polina Putrik, Sofia Ramiro, Francis Guillemin, Márta Péntek, Francisca Sivera, Tuulikki Sokka, Maarten De Wit, Anthony Woolf, Angela Zink, Daina AndersoneAbstract:OBJECTIVES: To describe and explore differences in formal regulations around sick leave and work disability (WD) for patients with rheumatoid arthritis (RA), as well as perceptions by Rheumatologists and patients on the system's performance, across European countries. METHODS: We conducted three cross-sectional surveys in 50 European countries: one on work (re-)integration and social security (SS) system arrangements in case of sick leave and long-term WD due to RA (one Rheumatologist per country), and two among approximately 15 Rheumatologists and 15 patients per country on perceptions regarding SS arrangements on work participation. Differences in regulations and perceptions were compared across categories defined by gross domestic product (GDP), type of social welfare regime, European Union (EU) membership and country RA WD rates. RESULTS: Forty-four (88%) countries provided data on regulations, 33 (75%) on perceptions of Rheumatologists (n=539) and 34 (77%) on perceptions of patients (n=719). While large variation was observed across all regulations across countries, no relationship was found between most of regulations or income compensation and GDP, type of SS system or rates of WD. Regarding perceptions, Rheumatologists in high GDP and EU-member countries felt less confident in their role in the decision process towards WD (β=-0.5 (95% CI -0.9 to -0.2) and β=-0.5 (95% CI -1.0 to -0.1), respectively). The Scandinavian and Bismarckian system scored best on patients' and Rheumatologists' perceptions of regulations and system performance. CONCLUSIONS: There is large heterogeneity in rules and regulations of SS systems across Europe in relation to WD of patients with RA, and it cannot be explained by existing welfare regimes, EU membership or country's wealth.
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advance and unmet need of health care for patients with rheumatoid arthritis in the german population results from the german rheumatoid arthritis population survey graps
Rheumatology, 2009Co-Authors: Gisela Westhoff, M Schneider, Heiner Raspe, Henning Zeidler, Claus Runge, Timm Volmer, Angela ZinkAbstract:Objectives. To assess the quality of health care for RA patients in the general population of Germany. Methods. A three-stage population survey was conducted to identify individuals with RA using a health care access panel (18–79 years; n ¼ 70 112). A 20-item postal screening questionnaire of musculoskeletal symptoms and diagnoses was followed by a detailed questionnaire for those who indicated the possibility of having RA. Respondents who fulfilled the modified ACR decision tree, who reported an RA diagnosis, care by a Rheumatologist or the use of DMARDs were asked to participate in a clinical examination by Rheumatologists who diagnosed the participants and rated the adequacy of treatment. Results. RA could not be ruled out in 1177 cases, of which 643 agreed to participate in the clinical examination, which was finally attended by 317 participants. Attendees did not differ with regard to any health or treatment measure from those who did not attend. Forty-one RA patients were detected. Of them, 93% had seen a Rheumatologist at least once and 63% within the last 12 months. A total of 73% had received DMARD therapy at some time and 59% were currently receiving it. An unmet need for DMARDs was discovered in 29% of the RA attendees. It pertained almost exclusively to the seronegative cases of which 29% had a need to start and 17% to increase a DMARD therapy according to the opinion of the examining Rheumatologist. Conclusion. Health care for RA patients has improved significantly since the last German RA survey in 1989. However, DMARD prescription still does not meet clinical recommendations, specifically in RF-negative patients. Since seronegative RA is a treatable disease, this group should not be overlooked.
A Laffon - One of the best experts on this subject based on the ideXlab platform.
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ultrasonographic assessment of inflammatory activity in rheumatoid arthritis comparison of extended versus reduced joint evaluation
Clinical and Experimental Rheumatology, 2005Co-Authors: Esperanza Naredo, G Bonilla, F Gamero, Jacqueline Uson, Loreto Carmona, A LaffonAbstract:Objective. To investigate the validity of reduced joint counts for ultrasonographic (US) assessment of joint inflammatory activity in patients with rheumatoid arthritis (RA). Methods. Ninety-four patients with RA were included. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were recorded for each patient. The presence of tenderness, swelling and a subjective swelling score from 0 to 3 were assessed by two Rheumatologists who reached consensus in 60 joints examined in each patient. All patients underwent an US examination by a third blinded Rheumatologist, using power Doppler (PD). US joint effusion, synovitis and PD signal were graded from 0 to 3 in the 60 joints. A 60-joint count and index for effusion, synovitis and PD signal were recorded. A 6-, 10-, 16-, 18-, and two 12-joint counts and indices for US parameters that included the most frequently US involved joints were calculated for each patient. Results. A 12-joint assessment for effusion, synovitis and PD signal, including bilateral wrist, second and third MCP, second and third PIP of hands and knee joints highly correlated with corresponding 60-joint US counts and indices. This reduced-joint US evaluation showed a similar correlation with clinical and laboratory parameters of disease activity to corresponding 60-joint assessment. Conclusion. We propose that a 12-joint evaluation may be a useful tool for US assessment of overall joint inflammatory activity in RA.
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assessment of inflammatory activity in rheumatoid arthritis a comparative study of clinical evaluation with grey scale and power doppler ultrasonography
Annals of the Rheumatic Diseases, 2004Co-Authors: Esperanza Naredo, G Bonilla, F Gamero, Jacqueline Uson, Loreto Carmona, A LaffonAbstract:Objective: To compare the clinical assessment of overall inflammatory activity in patients with rheumatoid arthritis (RA) with grey scale and power Doppler (PD) ultrasonography (US). Methods: Ninety four consecutive patients with RA were included. Demographic and clinical data, C reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) were recorded for each patient. The presence of tenderness, swelling, and a subjective swelling score from 1 to 3 were independently assessed by two Rheumatologists, who reached a consensus in 60 joints examined in each patient. All patients underwent a US examination by a third blinded Rheumatologist, using PD. US joint effusion, synovitis, and PD signal were graded from 1 to 3 in the 60 joints. Joint count and joint index for effusion, synovitis, and PD signal were recorded. A 28 joint count for clinical and US variables was calculated. Interobserver reliability of the US examination was evaluated by a fourth blinded Rheumatologist. Results: US showed significantly more joints with effusion (mean 15.2) and synovitis (mean 14.6) than clinical examination (mean 11.5, p Conclusion: US is a sensitive method for assessing joint inflammatory activity in RA, complementary to clinical evaluation.