Risk of Hematologic Malignancies in Elderly Patients With Ankylosing Spondylitis: A Cohort Study and Systematic Review.

OBJECTIVE: To examine the risk of hematologic malignancies in older adults with ankylosing spondylitis (AS). PATIENTS AND METHODS: We used US Medicare data from January 1, 1999, to December 31, 2010, to identify a population-based cohort of beneficiaries with AS. We also included beneficiaries with inflammatory bowel disease (IBD) as disease controls and beneficiaries without AS or IBD as unaffected controls. We excluded those treated with tumor necrosis factor inhibitors in this period. We followed up each group for new diagnosis claims for hematologic malignancies until September 30, 2015. RESULTS: We included 12,451 beneficiaries with AS, 234,905 with IBD, and 10,975,340 unaffected controls, with a mean follow-up of 9.9, 9.3, and 8.0 years, respectively. We identified 297 hematologic malignancies in the AS group, 4538 malignancies in the IBD group, and 128,239 malignancies in unaffected controls. The standardized incidence ratio in AS vs unaffected controls was 1.39 (95% CI, 1.05 to 1.61) for non-Hodgkin lymphoma, 1.50 (95% CI, 1.17 to 1.92) for chronic lymphocytic leukemia, and 1.52 (95% CI, 1.12 to 2.06) for multiple myeloma. Risks of acute myeloid leukemia and chronic myeloid leukemia were not elevated in AS, and there were too few cases of Hodgkin lymphoma to compute risks. Risks were comparable to those of beneficiaries with IBD. We also performed a systematic literature review of the risk of hematologic malignancy in AS, focusing on age associations, which have not been previously examined. We identified 21 studies in the systematic literature review, which included mainly young or middle-aged patients. Results suggested that AS was largely not associated with an increased risk of hematologic malignancies. Two cohort studies reported an increased risk of multiple myeloma in AS. CONCLUSION: The risks of non-Hodgkin lymphoma, chronic lymphocytic leukemia, and multiple myeloma are increased among elderly patients with AS.

Risk of 30-day Readmission After Knee or Hip Replacement in Rheumatoid Arthritis and Osteoarthritis by Non-Medicare and Medicare Payer Status.

OBJECTIVE: To determine the indication and risk of 30-day rehospitalization after hip or knee replacement among patients with rheumatoid arthritis (RA) and osteoarthritis (OA) by Medicare and non-Medicare status. METHODS: Using the Nationwide Readmission Database (2010-2014), we defined an index hospitalization as an elective hospitalization with a principal procedure of total hip (THR) or knee replacement (TKR) among adults aged ≥ 18 years. Primary payer was categorized as Medicare or non-Medicare. Survey logistic regression provided the odds of 30-day rehospitalization in RA relative to OA. We calculated the rates for principal diagnoses leading to rehospitalization. RESULTS: Overall, 3.53% of 2,190,745 index hospitalization had a 30-day rehospitalization. Patients with RA had a higher adjusted risk of rehospitalization after TKR (OR 1.11, 95% CI 1.02-1.21) and THR (OR 1.39, 95% CI 1.19-1.62). Persons with RA and OA did not differ with respect to rates of infections, cardiac events, or postoperative complications leading to the rehospitalization. After TKR, RA patients with Medicare had a lower venous thromboembolism (VTE) risk (OR 0.58, 95% CI 0.58-0.88), whereas those with RA had a greater VTE risk (OR 2.41, 95% CI 1.04-5.57) after THR. CONCLUSION: Patients with RA had a higher 30-day rehospitalization risk than OA after TKR and THR regardless of payer type. While infections, postoperative complications, and cardiac events did not differ, there was a significant difference in VTE as the principal diagnosis of rehospitalization.

Geographic Differences in Rates of Primary Total Knee Arthroplasty in Young and Older Adults: A Comparison of 3 US States.

OBJECTIVE: Rates of total knee arthroplasty (TKA) among Medicare beneficiaries (adults aged ≥ 65 yrs) vary across the United States, with higher rates in the Midwest and West than in the South. It is not known if a similar variation is present among younger patients, or if findings in Medicare reflect selective postponement of TKA in some regions. METHODS: Data on all primary TKA performed in adults aged ≥ 20 years in 3 states (Iowa, Utah, and Florida) in 2016 were obtained from state inpatient databases. Rates of TKA were computed based on population census data. Age-, sex-, and race-standardized rates were compared between Iowa and Florida, and between Utah and Florida, among adults aged 20-64 years and adults aged ≥ 65 years. RESULTS: There were 10,074, 8954, and 43,908 primary TKAs in Iowa, Utah, and Florida, respectively. Standardized rates were higher in Iowa and Utah than in Florida among both adults aged 20-64 years (Iowa:Florida rate ratio [RR] 1.89, 95% CI 1.79-1.99; Utah:Florida RR 2.31, 95% CI 2.18-2.45) and those aged ≥ 65 years (Iowa:Florida RR 1.41, 95% CI 1.35-1.47; Utah:Florida RR 1.77, 95% CI 1.70-1.85). Results were similar in sensitivity analyses limited to White patients, urban residents, and those with a diagnosis of knee osteoarthritis. CONCLUSION: TKA rates were higher in Iowa and Utah than in Florida among both younger adults and those aged ≥ 65 years, indicating that geographic differences are not specific to elderly patients.

Trends in Permanent Work Disability Associated With Rheumatoid Arthritis in the United States, 1999-2015.

OBJECTIVE: Advances in treatment over the past 20 years have resulted in improved control of rheumatoid arthritis (RA). The objective of our study was to investigate whether there has been a decrease in permanent work disability associated with RA in the US. METHODS: Medicare data from 1999 to 2015 were used to identify beneficiaries age 20-59 years with RA who became eligible for Medicare coverage under Social Security Disability Insurance. Diagnosis of RA was based on physician claims in the first year of enrollment. Annual rates of enrollment were sex- and age-standardized to the 2000 US population. RESULTS: The study included 97,787 beneficiaries with RA and Social Security Disability Insurance across all years. Medicare enrollment was 26.0 per million in 1999 and 26.0 per million in 2015. Rates increased following the Great Recession of 2008-2009 before returning to prerecession levels. There was no linear trend over time after adjusting for the annual national unemployment rate (relative risk 0.99 per year [95% confidence interval 0.99-1.00]; P = 0.69). Risks of work disability were much higher among workers over age 50 years. CONCLUSION: Based on Medicare enrollment by recipients of Social Security Disability Insurance, there was no decrease in permanent work disability among young and middle-age workers with RA in the US between 1999 and 2015.

Osteoarthritis Care and Risk of Total Knee Arthroplasty Among Medicare Beneficiaries: A Population-Based Study of Regional Covariation.

OBJECTIVE: To examine health care utilization among patients with knee osteoarthritis (OA) and assess whether utilization differs among residents of regions with high and low rates of total knee arthroplasty (TKA). METHODS: This was a retrospective cohort study of US Medicare beneficiaries with knee OA enrolled from 2005 to 2010. Health care utilization data for knee complaints, including rates of physician visits, physical therapy, knee injections, and arthroscopy, were abstracted from claims files until time of TKA or the end of the study in 2015. Utilization was compared among beneficiaries who lived in regions with high or low rates of TKA. RESULTS: Among 988,570 beneficiaries with knee OA, 327,499 (33.1%) underwent TKA during follow-up (median 5.6 years). Higher frequency of visits for knee complaints was associated with increased risk of TKA, whereas physical therapy, specialist care, and intraarticular treatments were associated with lower risk of TKA. Frequency of TKA varied from 26.4% in the lowest regional TKA rate quintile to 42.1% in the highest regional TKA rate quintile. Rates of physician visits, physical therapy, specialist care, and treatment with intraarticular injections varied inversely with regional TKA rate quintile. For example, 32.5% of beneficiaries in the lowest region quintile and 23.6% in the highest region quintile underwent physical therapy. Across all quintiles, physical therapy was associated with lower TKA rates. CONCLUSION: Dedicated nonsurgical OA care was infrequently used to treat elderly Americans with knee OA. Nonsurgical care was more common in regions with low TKA rates, suggesting reciprocal emphasis on medical treatment compared to surgical treatment across regions.

Accuracy of diagnoses of inflammatory arthritis in administrative hospitalization databases.

PURPOSE: Studies using administrative hospitalization data often classify patients as having inflammatory arthritis based on diagnoses recorded at the hospitalization. We examined the agreement of these diagnoses with patients' prior medical histories. METHODS: We identified Medicare beneficiaries hospitalized in 2011 to 2015 for total hip arthroplasty (THA), total knee arthroplasty (TKA), acute myocardial infarction (AMI), or sepsis. We compared diagnoses of rheumatoid arthritis (RA) or ankylosing spondylitis (AS) at the index hospitalization to diagnoses over prior inpatient and outpatient claims. To assess the impact of potential misclassification, we compared hospital outcomes using the alternative methods of detecting beneficiaries with arthritis. Analyses were repeated using Medicaid data. RESULTS: Among 506 781 Medicare beneficiaries with THA, 18282 had RA and 571 had AS at the arthroplasty hospitalization, while 13 212 had RA and 1519 had AS based on claims history. Diagnoses at the hospitalization were highly specific (0.98-0.99), but sensitivities (0.65 for RA; 0.31 for AS) and positive predictive values (PPV) (0.47 for RA; 0.83 for AS) were lower. For TKA, AMI, and sepsis, specificities were 0.97 to 0.99, sensitivities 0.60 to 0.66 for RA and 0.18 to 0.22 for AS, and PPVs 0.43 to 0.47 for RA and 0.73 to 0.77 for AS. In Medicaid, sensitivities were 0.21 to 0.67 for RA and 0.07 to 0.49 for AS. Frequencies of some hospital outcomes differed when arthritis was classified by the index hospitalization or claims history. CONCLUSION: Diagnoses of RA and AS in hospitalization databases are highly specific but fail to identify large proportions of patients with these diagnoses.

Regional Variation in Rates of Total Knee Arthroplasty Among Medicare Beneficiaries.

Importance: Rates of total knee arthroplasty vary widely across the United States. Whether this variation is associated with differences in patient characteristics or physician practice is unknown. Objectives: To determine regional variations in rates of total knee arthroplasty after accounting for the prevalence of knee arthritis and other potentially associated patient risk factors and to assess the correlation of these variations with measures of access to care and surgical indications. Design, Setting, and Participants: This retrospective national cohort study used Medicare data on more than 24 million deidentified beneficiaries annually from 2011 to 2015. Individuals included had fee-for-service coverage, were 65 to 89 years of age, and resided in 1 of 306 health referral regions. Data were analyzed from September 13, 2018, to August 15, 2019. Main Outcomes and Measures: Rate of primary total knee arthroplasty indexed to the national rate using observed to expected ratios. The expected numbers of arthroplasty procedures were derived from estimates based on beneficiaries' demographic and clinical characteristics. Observed to expected ratios were confounded by race/ethnicity; thus race/ethnicity-stratified analyses were conducted. Results: In 2011, there were 218 282 total knee arthroplasty procedures among 24 583 706 white Medicare beneficiaries (mean [SD] age 74.2 [6.9] years; 54.6% women). The rate of arthroplasty during the study period (5 years) was 9.3 per 1000 person-years. Adjustment for clinical characteristics reduced the spread in observed to expected ratios among regions by 29% compared with adjustment for age and sex alone. However, substantial variation remained, with observed to expected ratios that ranged from 0.61 in Newark, New Jersey, to 1.82 in Idaho Falls, Idaho. High ratios were primarily present in the upper Midwest, Great Plains, and Mountain West regions. Higher ratios were associated with regions where beneficiaries had fewer outpatient visits (Spearman correlation [r], -0.64; 95% CI, -0.70 to -0.56) and with regions having more surgeons per capita who performed knee arthroplasty (r = 0.27; 95% CI, 0.16-0.37). Higher ratios were associated with higher rates of arthroplasty procedures among beneficiaries with dementia (r = 0.36; 95% CI, 0.25-0.46), peripheral vascular disease (r = 0.52; 95% CI, 0.42-0.61), and skin ulcers (r = 0.43; 95% CI, 0.32-0.53), which are relative contraindications to arthroplasty. Conclusions and Relevance: Substantial regional variation in rates of total knee arthroplasty remained after adjustment for patient characteristics. Coexistence of high observed to expected ratios and high rates among patients at greater surgical risk suggested overuse of knee arthroplasty in some regions.

Increased Rates of Both Knee and Hip Arthroplasties in Older Patients with Ankylosing Spondylitis.

OBJECTIVE: To determine the risks of primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) in older patients with ankylosing spondylitis (AS). METHODS: We used administrative data from 1999 to 2013 on US Medicare beneficiaries to identify patients (< 75 yrs old) with AS and a comparison group without AS. Rates of primary THA and primary TKA were computed for each group, and standardized for age, sex, and race. We also examined risks of primary TKA among patients with AS by their THA status. RESULTS: We analyzed 52,568 patients with AS and 4,617,179 patients without AS. Between 1999 and 2013, the standardized incidence of primary THA in patients with AS doubled from 4.5 per 1000 patient-years (PY) to 9.6 per 1000 PY. Rates of primary TKA were higher in patients with AS than controls in all years. In 2013, the standardized incidence of primary TKA in AS was 12.3 per 1000 PY versus 5.7 per 1000 PY in the comparison group (RR 2.14, 95% CI 1.93-2.38). Rates of primary TKA were twice as high among patients with AS and THA than among those without THA (20.4 vs 10.2 per 1000 PY). CONCLUSION: Rates of THA in older patients with AS doubled over recent years, outpacing the increase in the general population. Rates of TKA were also substantially higher in older patients with AS. The increased risk of TKA in AS may be a consequence of damage from knee inflammation, or alterations in lower extremity biomechanics due to hip arthritis.

Minimal Clinically Important Improvement of Routine Assessment of Patient Index Data 3 in Rheumatoid Arthritis.

OBJECTIVE: To estimate minimal clinically important improvement (MCII) of RAPID-3 (Routine Assessment of Patient Index Data 3) in rheumatoid arthritis (RA). METHODS: RAPID-3 was computed before and after treatment escalation in a prospective study of adults with active RA. Patient judgment of improvement was used as the standard for a receiver-operating characteristic curve, from which MCII was estimated. RESULTS: Mean RAPID-3 improved from 16.3 to 11.1 between visits. MCII was -3.8 based on simultaneously optimized sensitivity and specificity, -3.5 using the 0.80 specificity criterion, and -4.1 using the Youden index. CONCLUSION: RAPID-3 improvement of 3.8/30 units appears clinically meaningful.

Lifetime Risks of Valvular Heart Disease and Pacemaker Use in Patients With Ankylosing Spondylitis.

Background The likelihoods of valvular heart disease ( VHD ) and conduction abnormalities in patients with ankylosing spondylitis ( AS p) are poorly defined. Knowing their lifetime risks of VHD and pacemaker use would help inform whether cardiac screening should be done. Methods and Results Patients with AS p and a comparison group without AS p were identified among US Medicare beneficiaries in 1999 to 2013. Frequencies of VHD and pacemaker use were compared in 4 age groups: 65 to 69 years, 70 to 74 years, 75 to 79 years, and 80 years or older, as were rates of valve surgeries, a measure of VHD severity, and new pacemaker insertions. Outcomes were compared between 42 327 patients with AS p and 19 211 703 patients without AS p. The prevalence of aortic valve disease in patients with AS p increased with age (2.6%, 6.7%, 10.9%, and 17.1%), as did the prevalence of mitral valve disease. Risks of VHD were slightly but significantly higher in patients with AS p (adjusted odds ratios 1.06-1.51). Rates of aortic valve replacement/repair were also higher in patients with AS p than in the comparison group (125 versus 93; 183 versus 149; 261 versus 208; 279 versus 191 per 100 000 patient-years in the 4 age groups). Rates of mitral valve surgery did not differ between groups. Among patients with AS p, pacemaker use ranged from 1.0% to 7.6% across age groups, and was slightly higher than in controls (odds ratio range 1.11-1.32). Conclusions Lifetime risks of VHD and pacemaker use in AS p increase markedly with age, but are only slightly higher than in elderly people without AS p.

Risk of total knee arthroplasty in young and middle-aged adults with ankylosing spondylitis.

The objective was to determine the risk of primary total knee arthroplasty (TKA) in young and middle-aged adults with ankylosing spondylitis (AS). We computed arthroplasty rates among US Medicaid recipients age 18 to 64 with AS and a comparison group without AS from 1999 to 2011. Among 14,714 patients with AS and 2,932,641 patients without AS, rates of primary TKA were 1.82-fold higher (95% confidence interval 1.57, 2.10) among patients with AS. The risk of primary TKA is elevated in young and middle-aged adults with AS.

Feasibility and assessment of outcome measures for yoga as self-care for minorities with arthritis: a pilot study.

BACKGROUND: While there is a growing interest in the therapeutic benefits of yoga, minority populations with arthritis tend to be under-represented in the research. Additionally, there is an absence of guidance in the literature regarding the use of multicultural teams and sociocultural health beliefs, when designing yoga studies for a racially diverse population with arthritis. This pilot study examined the feasibility of offering yoga as a self-care modality to an urban, bilingual, minority population with osteoarthritis (OA) or rheumatoid arthritis (RA), in the Washington, DC area. METHODS: The primary objective of the study was to assess the feasibility of offering an 8-week, bilingual yoga intervention adapted for arthritis to a convenience sample of primarily Hispanic and Black/African-American adults. A racially diverse interdisciplinary research team was assembled to design a study to facilitate recruitment and retention. The second objective identified outcome measures to operationalize potential facilitators and barriers to self-care and self-efficacy. The third objective determined the feasibility of using computer-assisted self-interview (CASI) for data collection. RESULTS: Enrolled participants (n = 30) were mostly female (93%), Spanish speaking (69%), and diagnosed with RA (88.5%). Feasibility was evaluated using practicality, acceptability, adaptation, and expansion of an arthritis-adapted yoga intervention, modified for this population. Recruitment (51%) and participation (60%) rates were similar to previous research and clinical experience with the study population. Of those enrolled, 18 started the intervention. For adherence, 12 out of 18 (67%) participants completed the intervention. All (100%), who completed the intervention, continued to practice yoga 3 months after completing the study. Using nonparametric tests, selected outcome measures showed a measurable change post-intervention suggesting appropriate use in future studies. An in-person computerized questionnaire was determined to be a feasible method of data collection. CONCLUSIONS: Findings from this pilot study confirm the feasibility of offering yoga to this racially/ethnically diverse population with arthritis. This article provides recruitment/retention rates, outcome measures with error rates, and data collection recommendations for a previously under-represented population. Suggestions include allocating resources for translation and using a multicultural design to facilitate recruitment and retention. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01617421.

Screening for depression in arthritis populations: an assessment of differential item functioning in three self-reported questionnaires.

PURPOSE: To determine if persons with arthritis differ systematically from persons without arthritis in how they respond to questions on three depression questionnaires, which include somatic items such as fatigue and sleep disturbance. METHODS: We extracted data on the Centers for Epidemiological Studies Depression (CES-D) scale, the Patient Health Questionnaire-9 (PHQ-9), and the Kessler-6 (K-6) scale from three large population-based national surveys. We assessed items on these questionnaires for differential item functioning (DIF) between persons with and without self-reported physician-diagnosed arthritis using multiple indicator multiple cause models, which controlled for the underlying level of depression and important confounders. We also examined if DIF by arthritis status was similar between women and men. RESULTS: Although five items of the CES-D, one item of the PHQ-9, and five items of the K-6 scale had evidence of DIF based on statistical comparisons, the magnitude of each difference was less than the threshold of a small effect. The statistical differences were a function of the very large sample sizes in the surveys. Effect sizes for DIF were similar between women and men except for two items on the Patient Health Questionnaire-9. For each questionnaire, DIF accounted for 8% or less of the arthritis-depression association, and excluding items with DIF did not reduce the difference in depression scores between those with and without arthritis. CONCLUSIONS: Persons with arthritis respond to items on the CES-D, PHQ-9, and K-6 depression scales similarly to persons without arthritis, despite the inclusion of somatic items in these scales.

Direct and Indirect Determinants of the Patient Global Assessment in Rheumatoid Arthritis: Differences by Level of Disease Activity.

OBJECTIVE: In rheumatoid arthritis (RA), the patient global assessment (PGA) has been strongly associated with pain severity, but less often with other measures, including disease activity measures. We tested whether RA activity and psychological measures had direct associations with the PGA or indirect associations that were mediated by pain. We also tested whether the correlates of the PGA differed with the degree of RA activity. METHODS: We studied 260 patients with active RA on 2 visits in a prospective longitudinal study. We used path analysis to test direct and indirect associations of Disease Activity Score in 28 joints (DAS28), morning stiffness, Health Assessment Questionnaire (HAQ), fatigue, physical role limitations, social functioning, depressive symptoms, and health distress with the PGA. RESULTS: Among the 509 visits, the median PGA score was 50 (25th-75th percentile: 24-66). Pain severity had the strongest association with the PGA, but direct associations were also found for morning stiffness severity, health distress, fatigue, and DAS28. Morning stiffness severity, DAS28, health distress, and HAQ were also indirectly associated with the PGA through pain. Among visits with DAS28 ≥5.4, pain, morning stiffness severity, and HAQ were the only determinants of the PGA. Among visits with DAS28 <4.2, health distress and age were additional determinants, and fatigue was marginally associated with the PGA. CONCLUSION: Although pain was the strongest determinant of the PGA in RA, morning stiffness severity, health distress, fatigue, and DAS28 were also important. Determinants of the PGA differed with RA activity, with health distress, age, and to a lesser degree, fatigue, contributing only in patients with less active RA.

Burden of Serious Infections in Adults With Systemic Lupus Erythematosus: A National Population-Based Study, 1996-2011.

OBJECTIVE: To compare rates of hospitalization for serious infections, trends in rates from 1996 to 2011, and in-hospital mortality between patients with systemic lupus erythematosus (SLE) and those without SLE in a national sample. METHODS: We analyzed hospitalizations for pneumonia, bacteremia/sepsis, urinary tract infections, skin infections, and opportunistic infections among adults in the Nationwide Inpatient Sample. We compared rates of hospitalization yearly among patients with SLE and the general population. We also computed odds ratios (ORs) for in-hospital mortality. RESULTS: In 1996, the estimated number of hospitalizations for pneumonia in patients with SLE was 4,382, followed by sepsis (2,305), skin infections (1,422), urinary tract infections (643), and opportunistic infections (370). Rates were much higher in patients with SLE than in those without SLE, with age-adjusted relative risks ranging from 5.7 (95% confidence interval [95% CI] 5.5-6.0) for pneumonia to 9.8 (95% CI 9.1-10.7) for urinary tract infection in 1996. Risks increased over time, so that by 2011, all relative risks exceeded 12.0. Overall risk of in-hospital mortality was higher in SLE only for opportunistic infections (adjusted OR 1.52 [95% CI 1.12-2.07]). However, in pneumonia and sepsis, mortality risks were higher in SLE among those who required mechanical ventilation. CONCLUSION: Hospitalization rates for serious infections in SLE increased substantially between 1996 and 2011, reaching over 12 times higher than in patients without SLE in 2011. Reasons for this acceleration are unclear. In-hospital mortality was higher among patients with SLE and opportunistic infections and those with pneumonia or sepsis who required mechanical ventilation.

Thirty-day hospital readmissions in systemic lupus erythematosus: predictors and hospital- and state-level variation.

OBJECTIVE: Systemic lupus erythematosus (SLE) has one of the highest hospital readmission rates among chronic conditions. This study was undertaken to identify patient-level, hospital-level, and geographic predictors of 30-day hospital readmissions associated with SLE. METHODS: Using hospital discharge databases from 5 geographically dispersed states, we studied all-cause readmission of SLE patients between 2008 and 2009. We evaluated each hospitalization as a possible index event leading up to a readmission, our primary outcome. We accounted for clustering of hospitalizations within patients and within hospitals and adjusted for hospital case mix. Using multilevel mixed-effects logistic regression, we examined factors associated with 30-day readmission and calculated risk-standardized hospital-level and state-level readmission rates. RESULTS: We examined 55,936 hospitalizations among 31,903 patients with SLE. Of these hospitalizations, 9,244 (16.5%) resulted in readmission within 30 days. In adjusted analyses, age was inversely related to risk of readmission. African American and Hispanic patients were more likely to be readmitted than white patients, as were those with Medicare or Medicaid insurance (versus private insurance). Several clinical characteristics of lupus, including nephritis, serositis, and thrombocytopenia, were associated with readmission. Readmission rates varied significantly between hospitals after accounting for patient-level clustering and hospital case mix. We also found geographic variation, with risk-adjusted readmission rates lower in New York and higher in Florida as compared to California. CONCLUSION: We found that ~1 in 6 hospitalized patients with SLE were readmitted within 30 days of discharge, with higher rates among historically underserved populations. Significant geographic and hospital-level variation in risk-adjusted readmission rates suggests potential for quality improvement.

Recent clinical trials in lupus nephritis.

Recent clinical trials have provided evidence for the efficacy of low-dose intravenous cyclophosphamide and mycophenolate mofetil as induction treatment for patients with proliferative lupus nephritis in comparative trials with standard-dose intravenous cyclophosphamide. Trials of maintenance treatments have had more variable results, but suggest that the efficacy of mycophenolate mofetil may be similar to that of quarterly standard-dose intravenous cyclophosphamide and somewhat more efficacious than azathioprine. Differential responses to mycophenolate mofetil based on ethnicity suggest that it may be more effective in black and Hispanic patients. Rituximab was not efficacious as an adjunct to induction treatment with mycophenolate mofetil.

Quality of care for incident lupus nephritis among Medicaid beneficiaries in the United States.

OBJECTIVE: We investigated the quality of care and factors associated with variations in care among a national cohort of Medicaid enrollees with incident lupus nephritis. METHODS: Using Medicaid Analytic eXtract files from 47 US states and the District of Columbia for 2000-2006, we identified a cohort of individuals with incident lupus nephritis. We assessed performance on 3 measures of health care quality: receipt of immunosuppressive, renal-protective antihypertensive, and antimalarial medications. We examined performance on these measures over 1 year and applied multivariable logistic regression models to understand whether sociodemographic, geographic, or health care access factors were associated with higher performance on quality measures. RESULTS: We identified 1,711 Medicaid enrollees with incident lupus nephritis. Performance on quality measures was low at 90 days (21.9% for immunosuppressive therapy, 44.0% for renal protection, and 36.4% for antimalarials) but increased by 1 year (33.7%, 56.4%, and 45.8%, respectively). Younger individuals, African Americans, and Hispanics were more likely to receive immunosuppressive therapy and hydroxychloroquine. Younger individuals were less likely to receive renal-protective antihypertensive medications. We found significant geographic variation in performance, with patients in the Northeast receiving higher quality of care compared to other regions. Poor access to health care, as assessed by having a greater number of treat-and-release emergency department visits compared to ambulatory encounters, was associated with lower receipt of recommended treatment. CONCLUSION: These nationwide data suggest low overall quality of care and potential delays in care for Medicaid enrollees with incident lupus nephritis. Significant regional differences also suggest room for quality improvement.

Sense of control and self-reported health in a population-based sample of older Americans: assessment of potential confounding by affect, personality, and social support.

BACKGROUND: Sense of control has been linked to improved health outcomes, but it is unclear if this association is independent of other psychosocial factors. PURPOSE: The aim of this study is to test the strength of association between sense of control and self-reported health after adjustment for positive and negative affect, "Big 5" personality factors, and social support. METHOD: Data on sense of control (measured by personal mastery, perceived constraints, and a health-specific rating of control), affect, personality, social support, and two measures of self-reported health (global rating of fair or poor health and presence of functional limitations) were obtained on 6,891 participants in the Health and Retirement Study, a population-based survey of older Americans. The cross-sectional association between sense of control measures and each measure of self-reported health was tested in hierarchical logistic regression models, before and after adjustment for affect, personality, and social support. RESULTS: Participants with higher personal mastery were less likely to report fair/poor health (odds ratio 0.76 per 1-point increase) while those with higher perceived constraints were more likely to report fair/poor health (odds ratio 1.37 per 1-point increase). Associations remained after adjustment for affect, but adjustment for affect attenuated the association of personal mastery by 37% and of perceived constraints by 67%. Further adjustment for personality and social support did not alter the strength of association. Findings were similar for the health-specific rating of control, and for associations with functional limitations. CONCLUSION: Sense of control is associated with self-reported health in older Americans, but this association is partly confounded by affect.