Economic impact of informal caring for a person with arthritis in Australia from 2015 to 2030: a microsimulation approach using national survey data.

OBJECTIVES: To estimate the economic burden of informal caregivers not in the labour force (NILF) due to caring for a person with arthritis in Australia, with projections of these costs from 2015 to 2030. DESIGN: Static microsimulation modelling using national survey data. SETTING: Australia nationwide survey. PARTICIPANTS: Participants include respondents to the Survey of Disability, Ageing and Carers who are informal carers of a person who has arthritis as their main chronic condition and non-carers. OUTCOME MEASURES: Estimating the economic impact and national aggregated costs of informal carers NILF to care for a person with arthritis and projecting these costs from 2015 to 2030 in 5-year intervals. RESULTS: On a per-person basis, when adjusted for age, sex and highest education attained, the difference in average weekly total income between informal carers and non-carers employed in the labour force is $A1051 (95% CI: $A927 to $A1204) in 2015 and projected to increase by up to 22% by 2030. When aggregated, the total national annual loss of income to informal carers NILF is estimated at $A388.2 million (95% CI: $A324.3 to $A461.9 million) in 2015, increasing to $A576.9 million (95% CI: $A489.2 to $A681.8 million) by 2030. The national annual tax revenue lost to the government of the informal carers NILF is estimated at $A99 million (95% CI: $A77.9 to $A126.4 million) in 2015 and is projected to increase 49% by 2030. CONCLUSION: Informal carers NILF are economically worse off than employed non-carers, and the aggregated national annual costs are substantial. The future economic impact of informal carers NILF to care for a person with arthritis in Australia is projected to increase, with the estimated differences in income between informal carers and employed non-carers increasing by 22% from 2015 to 2030.

A post hoc comparative real-world analysis of HEAD-US score for joint health assessment of patients with severe haemophilia A and B in Spain.

AIM: Joint damage due to haemarthrosis can be effectively monitored with point-of care ultrasound using the Haemophilia Early Arthropathy Detection with US (HEAD-US) scoring system. A post hoc comparative analysis of the joint status of patients with severe haemophilia A (HA) or B (HB) was performed. METHODS: The databases of two observational, cross-sectional studies that recruited patients with HA or HB from 12 Spanish centres were analysed to compare the status of the elbows, knees and ankles in patients with severe disease according to treatment modality. The HEAD-US score was calculated in both studies by the same trained operators. RESULTS: Overall, 95 HA and 41 HB severe patients were included, with a mean age of 35.2 ± 11.8 and 32.7 ± 14.2 years, respectively. The percentage of patients who received prophylaxis, over on-demand (OD) treatment, was much higher in HA (91.6%) than in HB (65.8%) patients. With a similar number of target joints, the HEAD-US score was zero in 6.3% HA and 22.0% HB patients (p < .01), respectively. The HA population showed significantly worse HEAD-US scores. Whilst osteochondral damage occurred more frequently in patients OD or tertiary prophylaxis, our data suggest that articular damage is less prominent in primary/secondary prophylaxis, regardless of the type of haemophilia. These latter treatment modalities were also associated with a lower prevalence of synovial hypertrophy, particularly in HB patients. CONCLUSION: This post hoc analysis indicates that joint status seems to be significantly influenced by haemophilia type (HA or HB) and treatment modality in these severe Spanish populations with severe disease. Continuing HEAD-US monitoring for the early detection and management of intra-articular abnormalities, as well as more efficiently tailored therapies should be warranted.

Assessment of antiarthritic potential of Asparagus dumosus using formaldehyde and CFA-induced arthritic models in rats via modulation of oxidative stress biomarkers and mRNA expression of IL-1b, IL-6, RANKL, OPG, TNF-α and COX-2.

Medicinal plants play a pivotal role in the prevention of chronic non-communicable diseases including arthritis. Despite the traditional use of Asparagus dumosus in arthritis, it has not been studied yet for its effectiveness in arthritis. This study was aimed to explore the antiarthritic potential of A. dumosus in formaldehyde and complete Freund's adjuvant (CFA)-induced arthritic rats. Body weight, arthritic index, hepatic oxidative stress, hematological, biochemical and inflammatory markers were assessed using ELISA, whilst qRT-PCR studies were carried out for the mRNA expression of IL-1b, IL-6, RANKL, OPG, TNF-α and COX-2 genes. GCMS and HPLC analysis were performed to identify the secondary metabolites of A. dumosus. From day 8 to 28 post-administration of formaldehyde and CFA, oral administration of A. dumosus (600, 300 and 150 mg/kg) showed a noteworthy improvement (p < 0.001) in the body weights, immune organ weights, serum levels of rheumatoid (RA) factor, C-reactive protein, TNF-α and IL-6 levels in arthritic rats similar to the effect of piroxicam and methotrexate. Subsequently, the administration of A. dumosus to formaldehyde and CFA-challenged rats, caused a marked decrease (p < 0.001) in the mRNA expression of IL-1b, IL-6, OPG, RANKL, TNF-α and COX-2 genes in treated rats. Likewise, when assessed for antioxidant potential, A. dumosus produced a pronounced (p < 0.001) reduction in malondialdehyde (MDA) levels and hydrogen peroxide (H2O2) production, whilst a dose-dependent (p < 0.001) increase in catalase (CAT) and superoxide dismutase (SOD) activities was recorded. GCMS profiling of A. dumosus presented benzaldehyde, 3-hydroxy-4-methoxy-, 1-decanol and undecane as plant compositions, whereas HPLC fingerprinting displayed quercetin, benzaldehyde, 3-hydroxy-4-methoxy-, gallic acid and cinnamic acid as plants constituents. These results depict that A. dumosus possesses anti-arthritic effect mediated possibly through attenuation of arthritic indices, chronic inflammatory and oxidative stress biomarkers along with down-regulation in the mRNA expression of arthritic candid genes.

A single-centre experience of 29 total ankle replacement in haemophiliac patients: Therapeutic management, factor consumption and cost.

INTRODUCTION: In patients with haemophilia, repeated bleeding in large joints leads to chronic haemophilic arthropathy, a rare disease that can be managed surgically with ankle arthrodesis or with total ankle replacement (TAR). TAR has been reported to provide good surgical results in the medium/long-term and allow preservation of joint mobility but the medical therapeutic management of the patients has not been described. AIM: To describe the medical therapeutic management of TAR. METHODS: All patients with haemophilia A/B, with haemophilic ankle arthropathy, and who underwent TAR between April 2006 and October 2019 were retrospectively included. Factor consumption, perioperative and early complications, volume of blood lost, and orthopaedic data were collected. RESULTS: A total of 25 patients underwent 29 TAR (mean age was 44.7 years [range: 26-65]). In the 17 patients with HA without history of anti-FVIII inhibitor, the mean ± SD consumption the day of surgery was 116 ± 16 UI/kg when clotting factors were administered by continuous infusion, 106 ± 13 UI/kg when SHL factors were administered by bolus infusion, and 75 ± 22 UI/kg when EHL factors were administered by bolus infusion. During hospitalisation, the mean factor cost was €38,073 (83.7% of the total cost of surgery). Mean blood loss was significantly lower in patients treated with tranexamic acid (164 mL, range: 40-300) than in those not (300 mL, range: 70-800; p = .01). Six patients had haematoma. The 10-year survival free of any prosthesis removal/arthrodesis was estimated to be 92.2% (95% CI [83; 100]). CONCLUSION: The medical therapeutic management of TAR is complex, carried out by a multidisciplinary team but effective in avoiding the occurrence of complications.

Complication rates following reverse and anatomic shoulder replacement in treatment of glenohumeral arthritis: a 10-year Medicare review study.

BACKGROUND: We sought to compare the complication rates after anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) for primary glenohumeral arthritis in a Medicare population. METHODS: Patients who underwent a shoulder arthroplasty were identified from the 5% subset of Medicare parts A/B between 2009 and 2019. Patients with less than 1-year follow-up were excluded. A total of 8846 patients with a diagnosis of glenohumeral arthritis were then subdivided into those who received aTSA (5935 patients) and RSA (2911 patients). A multivariate Cox regression analysis was then performed comparing complication rates at 3 months, 6 months, 1 year, 2 years, and 5 years. RESULTS: Statistically significant increased rates of instability (hazard ratio [HR] = 1.46), fracture of the scapula (HR = 7.76), infections (HR = 1.45), early revision (HR = 1.79), and all complications (HR = 1.32) were seen in the RSA group. There was no significant difference in revision rate at 5 years between the 2 groups. There was no difference in patient characteristics or comorbid conditions (smoking status, diabetes, Charlson score, etc.) or hospital characteristics (location, teaching status, public vs. private, etc.) between the 2 groups. CONCLUSION: An increased rate of early complications was observed with the use of RSA compared with aTSA for the treatment of primary glenohumeral arthritis, including instability, scapula fracture, infection, and all cause complication. No difference in revision rate between RSA and aTSA at 5 years was observed.

Social determinants of health in patients with arthritis: a cross-sectional analysis of the 2017 Behavioral Risk Factor Surveillance System.

CONTEXT: Social determinants of health (SDOH) are economic, social, and political conditions that affect a person's overall health or the health of a group of people. Researchers have investigated the effects of SDOH on various diseases, such as asthma, obesity, and chronic stress, but few publications have been made regarding its effects on arthritis. OBJECTIVES: Our primary objective was to analyze the implications of SDOH on disease severity relating to pain levels and limitations experienced among people with diagnosed arthritis. METHODS: We performed a cross-sectional analysis of the 2017 Behavioral Risk Factor Surveillance System (BRFSS). We included individuals who reported having arthritis, were over the age of 45, and who also completed the SDOH module. Pain scores from the four-question Arthritis Burden Module were correlated to question responses pertaining to SDOH to determine their associations. RESULTS: For the analysis, our sample size was 25,682, with response rates varying slightly among the SDOH questions. Individuals diagnosed with arthritis were more likely to report functional limitations if they experienced food insecurity (χ2=234.0, p<0.001), financial instability (χ2=149.7, p<0.001), or frequent stress (χ2=297.6, p<0.001). Further, we found that individuals with arthritis experiencing any domain of SDOH reported higher mean pain scores than those not experiencing that domain, with the highest pain score difference among those reporting frequent stress (Coefficient: 1.93, CI=1.74-2.13, t=19.43, p<0.001). CONCLUSIONS: Our results show that SDOH profoundly impact pain levels and limitations experienced by patients with arthritis. Although work has already begun to help alleviate burdens associated with SDOH, more research and actions are required to create equitable health throughout the population.

Risk Factors for Food Insecurity among Older Adults in India: Study Based on LASI, 2017-2018.

BACKGROUND: Food security is linked to the nutritional status and well-being of older adults. India is a rapidly aging nation that ranks highly on the 2022 Global Hunger Index. This paper examines the prevalence and risk factors of food insecurity in India's older population. METHODS: We used data from the 2017-2018 Longitudinal Aging Study in India. The sample size was 31,532 adults aged 60 years and above. Food insecurity was measured using a four-item version of the Food Insecurity Experience scale. Multivariable logistic regressions using individual-level weights were implemented to assess the risk factors of food insecurity. RESULTS: The prevalence of food insecurity was 10.5% in the weighted sample. Sociodemographic factors were important in explaining food insecurity. Older adults who were male, younger, lowly educated, socially disadvantaged, in rural areas, and outside the Northern region were most vulnerable to food insecurity, controlling for various confounders. Additionally, low economic status, no occupational pension, currently working, social isolation, physical impairment, functional disabilities, poor self-rated health, and arthritis were associated with an increased risk of food insecurity. CONCLUSIONS: More active food assistance programs catering to older adults and a better provision of economic and social security are warranted to establish a food-secure environment for rapidly aging India.

[Immuno-inflammatory mechanisms of hypertension : contribution to the clinic]. / Mécanismes immuno-inflammatoires de l'HTA : apport à la clinique.

In both industrialized and developing countries, the prevalence of hypertension is increasing. The classical pathophysiology of this major cardiovascular risk factor has recently been enriched by new concepts involving the inflammation and the immune system as potential players. Indeed in certain immune-mediated inflammatory diseases such as psoriatic arthritis, rheumatoid polyarthritis or lupus erythematosus, but also degenerative arthritis, periodontitis, arterial hypertension is found more frequently than in the general population, often underdiagnosed and poorly controlled, and the cardiovascular (CV) risk is more important. The aim of this article is to review the state of knowledge on this subject, and to draw out any implications for clinical practice.

La prévalence de l'hypertension artérielle est en constante augmentation tant dans les pays industrialisés que dans ceux à bas revenus. La physiopathologie classique de ce facteur de risque cardiovasculaire (CV) majeur s'est récemment enrichie de nouveaux concepts mettant en jeu l'inflammation et le système immunitaire comme acteurs potentiels. En effet, dans certaines maladies auto-immunes ou inflammatoires à médiation immunitaire, comme le psoriasis, la polyarthrite rhumatoïde ou le lupus érythémateux disséminé, mais aussi les arthropathies dégénératives, la parodontite, on retrouve plus fréquemment une hypertension artérielle qu'au sein de la population générale, souvent sous-diagnostiquée et mal contrôlée, et le risque CV y est plus important. Le but de cet article est de faire le point sur l'état des connaissances à ce sujet, et d'en tirer d'éventuelles implications pour la clinique.

Association between arthritis and hand grip strength indices combined with anthropometry in an older Korean population.

BACKGROUND: Hand grip strength (HGS) is related to arthritis and all-cause mortality. Many studies have examined the association between HGS and arthritis, but these studies did not consider relative HGS indices. The objectives of this study were to examine the association between arthritis and HGS indices in an older Korean population and to compare an absolute HGS index and a relative HGS indices. METHODS: In a large-scale cross-sectional study, a total of 16,860 subjects older than 50 years from the Korea National Health and Nutrition Survey from 2014 to 2019 were included for statistical analysis. A binary logistic regression model was used to examine the association between arthritis and HGS indices in crude and covariate-adjusted models. RESULTS: In the crude analysis, all anthropometric and HGS indices were associated with arthritis except for weight in men. In adjusted models 1 and 2, among the anthropometric indices, waist circumference (WC) and waist-to-height ratio (WHtR) were associated with arthritis in men but not in women. Absolute HGS and all relative HGS indices showed a negative association with arthritis among both men and women, and the magnitude of the association of arthritis with the absolute HGS index and the relative HGS indices was similar. However, the magnitude of the association between all HGS indices and arthritis was higher for men than for women except in the crude analysis. DISCUSSION: Absolute and relative HGS indices had negative associations with arthritis, and the magnitude of the association between the absolute HGS index and arthritis and between the relative HGS indices and arthritis was similar in all models. To our knowledge, this is the first report of an association between arthritis and relative HGS indices, which was not observed in previous studies.

The role of occupational therapy in providing vocational rehabilitation for inflammatory arthritis: A scoping review protocol.

INTRODUCTION: Inflammatory arthritis (IA) significantly impacts people's ability to continue in work roles, despite advances in medical management. Employment is acknowledged as important for health and wellbeing. Facilitating work participation and employment reduces social welfare dependence for income, minimising societal cost. Internationally, pathways and processes are developing to maintain people with acquired conditions in the workplace. Occupational Therapy supports this process, with its biopsychosocial approach, giving a framework to consider the complex dynamic of a person's vocational rehabilitation (VR) needs. A scoping review framework was chosen to explore the diverse VR process and emerging focus on Occupational Therapy's role in providing VR for the IA population. METHODS: The methodological framework for scoping reviews will be used to guide the process and structure of the scoping review. A search strategy will be implemented in all the major peer reviewed databases along with grey literature repositories for English language studies. Study selection will use the PRISMA-ScR flow chart against an agreed eligibility criteria by two independent reviewers. Data extraction from the final selection will be mapped out using tables and a supporting descriptive review reflecting on the original scoping review aim and objectives completed. DISSEMINATION: Findings will be disseminated at all levels and in various formats to bring them to the attention of clinicians, researchers and policy makers as VR pathways are established and prioritised for the early IA population.

Deep learning-based assessment of knee septic arthritis using transformer features in sonographic modalities.

PURPOSE: Septic arthritis is an infectious disease. Conventionally, the diagnosis of septic arthritis can only be based on the identification of causal pathogens taken from synovial fluid, synovium or blood samples. However, the cultures require several days for the isolation of pathogens. A rapid assessment performed through computer-aided diagnosis (CAD) would bring timely treatment. METHODS: A total of 214 non-septic arthritis and 64 septic arthritis images generated by gray-scale (GS) and Power Doppler (PD) ultrasound modalities were collected for the experiment. A deep learning-based vision transformer (ViT) with pre-trained parameters were used for image feature extraction. The extracted features were then combined in machine learning classifiers with ten-fold cross validation in order to evaluate the abilities of septic arthritis classification. RESULTS: Using a support vector machine, GS and PD features can achieve an accuracy rate of 86% and 91%, with the area under the receiver operating characteristic curves (AUCs) being 0.90 and 0.92, respectively. The best accuracy (92%) and best AUC (0.92) was obtained by combining both feature sets. CONCLUSIONS: This is the first CAD system based on a deep learning approach for the diagnosis of septic arthritis as seen on knee ultrasound images. Using pre-trained ViT, both the accuracy and computation costs improved more than they had through convolutional neural networks. Additionally, automatically combining GS and PD generates a higher accuracy to better assist the physician's observations, thus providing a timely evaluation of septic arthritis.

A Retrospective, Long-term Follow-up of the Clinical Outcomes and Cost-effectiveness of Single-anesthetic Multiple Total Joint Procedures in Hemophilic Arthropathy.

OBJECTIVE: Although total joint replacement (TJR) procedures are efficacious, perioperative high-dose factors replacement therapy (FRT) to avoid catastrophic bleeding represents a significant hurdle, particularly for patients with multiple joint affection. Double simultaneous bilateral TJRs were reported as safe and cost-effective. However, little is known about multiple TJRs. The feasibility and effects remain debatable. Surgeons need to weigh the high cost of FRT against safety. Accordingly, we aimed to evaluate the clinical outcomes and cost-effectiveness of single-anesthetic multiple-joint procedures of lower limbs in end-stage hemophilic arthropathy. METHODS: Our retrospective cohort study retrieved data from an inpatient database of patients with hemophilia who underwent total knee arthroplasty (TKA), total hip arthroplasty (THA), and/or ankle arthrodesis from January 2000 to April 2016. Complications, hospital stays, transfusion, doses of clotting factor, medical costs, range of motion (ROM), Harris hip scores (HHSs) and Hospital for special surgery knee scores (HSSs) were recorded. A P value < 0.05 was considered significant. RESULTS: A total number of 81 patients were included in this study, among which 89 TKAs and 52 THAs were performed. Compared to the single TJR group, the simultaneous multiple TJR group showed a significantly higher rate of blood transfusions (P < 0.05). But no significant differences were found in the length of hospital stays, factor consumption, hospitalization costs excluding prosthesis expenses, and total complication rates. Finally, similar postoperative ROM, HHS, and HSS were witnessed in two groups (P value > 0.05). CONCLUSION: Our data indicated that simultaneous multiple TJRs are a safe and cost-effective choice for treating hemophilic patients with multiple HA-affected lower limb joints.

Reach and Impact of In-Person and Remote Delivery Formats of Walk with Ease.

This descriptive study retrospectively evaluates the reach and impact of cohorts enrolled in Group (in-person, 2017-2020) and Self-Directed (remote, 2019-2020) delivery formats of the evidenced-based health promotion program, Walk with Ease, implemented statewide in North Carolina. An existing dataset consisting of pre- and post-surveys were analyzed for 1,890 participants; 454 (24%) from the Group format and 1,436 (76%) from Self-Directed. Self-Directed participants were younger, had more years of education, represented more Black/African American and multi-racial participants, and participated in more locations than Group, though a higher percentage of Group participants were from rural counties. Self-Directed participants were less likely to report having arthritis, cancer, chronic pain, diabetes, heart disease, high cholesterol, hypertension, kidney disease, stroke, or osteoporosis, though more likely to report being obese or having anxiety or depression. All participants walked more and expressed higher confidence in managing joint pain following the program. These results promote opportunities for enhancing engagement in Walk with Ease with diverse populations.

Prevalence of multimorbidity combinations and their association with medical costs and poor health: A population-based study of U.S. adults.

Background: Multimorbidity is common, but the prevalence and burden of the specific combinations of coexisting disease has not been systematically examined in the general U.S. adult population. Objective: To identify and estimate the burden of highly prevalent combinations of chronic conditions that are treated among one million or more adults in the United States. Methods: Cross-sectional analysis of U.S. households in the Medical Expenditure Panel Survey (MEPS), 2016-2019, a large nationally-representative sample of the community-dwelling population. Association rule mining was used to identify the most common combinations of 20 chronic conditions that have high relevance, impact, and prevalence in primary care. The main measures and outcomes were annual treated prevalence, total medical expenditures, and perceived poor health. Logistic regression models with poor health as the outcome and each multimorbidity combination as the exposure were used to calculate adjusted odds ratios and 95% confidence intervals. Results: Frequent pattern mining yielded 223 unique combinations of chronic disease, including 74 two-way (dyad), 115 three-way (triad), and 34 four-way combinations that are treated in one million or more U.S. adults. Hypertension-hyperlipidemia was the most common two-way combination occurring in 30.8 million adults. The combination of diabetes-arthritis-cardiovascular disease was associated with the highest median annual medical expenditures ($23,850, interquartile range: $11,593-$44,616), and the combination of diabetes-arthritis-asthma/COPD had the highest age-race-sex adjusted odds ratio of poor self-rated health (adjusted odd ratio: 6.9, 95%CI: 5.4-8.8). Conclusion: This study demonstrates that many multimorbidity combinations are highly prevalent among U.S. adults, yet most research and practice-guidelines remain single disease focused. Highly prevalent and burdensome multimorbidity combinations could be prioritized for evidence-based research on optimal prevention and treatment strategies.

Changes in coverage among non-elderly adults with chronic diseases following Affordable Care Act implementation.

IMPORTANCE: Changes in insurance coverage after the Affordable Care Act (ACA) among non-elderly adults with self-reported chronic conditions across income categories have not been described. OBJECTIVE: To examine changes in insurance coverage after the ACA among non-elderly adults with chronic conditions across income categories, by geographic region. DESIGN: We compared self-reported access to health insurance pre-ACA (2010-2013) and post-ACA (2014-2017) for individuals 18-64 years of age with ≥ 2 chronic conditions, including hypertension, heart disease/stroke, emphysema, diabetes, asthma, cancer, and arthritis, across regions using a logistic regression approach, adjusted for covariates. We also assessed U.S. Census regional differences in insurance coverage post-ACA using modified Poisson regression models with robust variance and calculated the risk ratio (RR) of being uninsured by region, with the Northeast as the reference category. Within each region, we then examined changes in insurance coverage by income level among non-elderly individuals with any chronic condition. SETTING: 2010-2017 household component of the nationally representative Medical Expenditure Panel Survey (MEPS). PARTICIPANTS: All members of surveyed households during five interviews over a two-year period. INTERVENTION: Start of insurance coverage expansion under the ACA. MAIN OUTCOMES: Health insurance status. RESULTS: On average nationwide, non-elderly adults with self-reported chronic conditions experienced increased insurance coverage associated with the ACA (diabetes: +6.41%, high-blood pressure: +6.09%, heart disease: +6.50%, asthma: +6.37%, arthritis: +6.77%, and ≥ 2 chronic conditions: +6.39%). Individuals in the West region reported the largest increases (diabetes +9.71%, high blood pressure +8.10%, and heart disease/stroke +8.83 %, asthma +9.10%, arthritis +8.39%, and ≥ 2 chronic conditions +8.58). In contrast, individuals in the South region reported smaller increases in insurance coverage post-ACA among those with diabetes, heart disease/stroke, and asthma compared to the Midwest and West. The Northeast region, which had the highest levels of insurance coverage pre-ACA, exhibited the smallest increase in reported coverage post-ACA. Reported insurance coverage improved across all regions for adults with any chronic condition across income levels, most notably for very low- and low-income individuals. A further cross-sectional comparison after the ACA demonstrated important residual differences in insurance coverage, despite the gains in all regions. When compared to the Northeast, adults with any self-reported chronic conditions living in the South were more likely to report no insurance coverage (diabetes: RR 1.99, p-value <0.001, high blood pressure: RR 2.02, p-value <0.001, heart diseases/stroke: RR 2.55, p-value <0.001, asthma RR 2.21, p-value <0.001, arthritis: RR 2.25, p-value <0.001), and ≥ 2 chronic condition (RR 2.29, p-value <0.001). CONCLUSION AND RELEVANCE: The ACA was associated with meaningful increases in insurance coverage for adults with any self-reported chronic condition in all US regions, most notably in the West region and among those with lower incomes, suggesting a nation-wide trend to improved access to health insurance following implementation. However, intra-regional comparisons after ACA implementation showed important differences. Individuals with ≥2 chronic conditions in the South were 2.29 times less likely to have insurance coverage in comparison to their peers in the Northeast. Though the post-ACA improvements in reported access to health insurance coverage affected all US regions, the reported experience of those with multiple chronic conditions in the South point to continued barriers for those most likely to benefit from access to health insurance coverage. Medicaid expansion in the South would likely result in increased insurance coverage for individuals with chronic conditions and improve health care outcomes.

The Workwell trial: protocol for the process evaluation of a randomised controlled trial of job retention vocational rehabilitation for employed people with inflammatory arthritis.

BACKGROUND: The Workwell trial is a multi-centre randomised controlled trial with the aims of evaluating the effectiveness and cost-effectiveness of job retention vocational rehabilitation for employed people with inflammatory arthritis, who are experiencing work difficulties due to their arthritis. Vocational rehabilitation is delivered by health service occupational therapists, who have received additional training in providing this Workwell intervention. A process evaluation will be undertaken alongside the main trial to investigate implementation fidelity; understand key stakeholders' perspectives of the intervention and the social and structural context in which the intervention is provided; and explore issues related to future implementation in clinical practice. This protocol describes the aims, objectives, and methodology of the Workwell trial process evaluation. METHODS: This mixed methods process evaluation will follow the Medical Research Council's Guidance on process evaluations for complex interventions. It will be underpinned by the conceptual framework for implementation fidelity (CFIF) and normalisation process theory (NPT). We will analyse treatment records, work assessments, and treatment notes to ascertain implementation fidelity. Semi-structured interviews with trial participants, their employer/line managers, treating therapists, and their therapy service managers will be undertaken to explore perceptions of the intervention, contextual factors, and potential for future implementation in practice. Interview topic guides will be informed by NPT. Therapists' views about Workwell training will be explored via questionnaires following training, and interviews and focus groups following treatment delivery to inform future implementation. Quantitative data will be analysed descriptively. Qualitative data will be analysed using thematic analysis. NPT will guide data analysis and interpretation. Findings from the different elements of this embedded design process evaluation will be reported separately and then the elements integrated. The process evaluation data will be analysed independently of the Workwell trial outcome evaluation. The process evaluation data will then be reviewed in the light of the trial findings. DISCUSSION: Few trials of job retention vocational rehabilitation in arthritis have included process evaluations. This process evaluation will assist in understanding factors influencing trial outcomes and identifying potential contextual barriers and facilitators for the potential implementation of Workwell vocational rehabilitation into clinical services. TRIAL REGISTRATION: ClinicalTrials.gov NCT03942783 . Registered on 08 May 2019. ISRCTN Registry ISRCTN61762297 . Registered on 13 May 2019. Retrospectively registered.

Development and real-life use assessment of a self-management smartphone application for patients with inflammatory arthritis. A user-centred step-by-step approach.

BACKGROUND: Mobile health applications (apps) are increasing in interest to enhance patient self-management. Few apps are actually used by patients and have been developed for patients with inflammatory arthritis (IA) treated with disease-modifying anti-rheumatic drugs which use entails risk of adverse effects such as infections. OBJECTIVE: To develop Hiboot, a self-management mobile app for patients with IA, by using a user-centred step-by-step approach and assess its real-life use. METHODS: The app development included first a qualitative study with semi-guided audiotaped interviews of 21 patients to identify the impact of IA on daily life and patient treatments practices and an online cross-sectional survey of 344 patients to assess their health apps use in general and potential user needs. A multidisciplinary team developed the first version of the app via five face-to-face meetings. After app launch, a second qualitative study of 21 patients and a users' test of 13 patients and 3 rheumatologists led to the app's current version. The number of app installations, current users and comments were collected from the Google Play store and the Apple store. RESULTS: The qualitative study revealed needs for counselling, patient-health professional partnership, and skills to cope with risk situations; 86.8% participants would be ready to use an app primarily on their rheumatologist's recommendation. Six functionalities were implemented: a safety checklist before treatment administration, aids in daily life situations based on the French academic recommendations, treatment reminders, global well-being self-assessment, periodic counselling messages, and a diary. The Hiboot app was installed 20,500 times from September 2017 to October 2020, with 4300 regular current users. Scores were 4.4/5 stars at Android and iOS stores. CONCLUSION: Hiboot is a free self-management app for patients with IA developed by a step-by-step process including patients and health professionals. Further evaluation of the Hiboot benefit is needed.

Barriers and facilitators for implementation of a digital referral algorithm for inflammatory arthritis - a qualitative assessment in patients and caregivers.

PURPOSE: Difficulty to recognize inflammatory rheumatic diseases (IRD) in a primary care setting leads to late referral to secondary care. An evidence-based digital referral algorithm can support early referral, yet implementation in daily practice only succeeds with support of end users. We aim to understand the context of implementing a digital referral algorithm and explore the potential barriers and facilitators to implementation. METHODS: This qualitative study comprised focus groups and an online survey. Focus groups were performed with patients from outpatient rheumatology clinics. Surveys were sent out to general practitioners and rheumatologists distributed over The Netherlands. The presented digital referral algorithm originates from the JOINT referral study. Thematic analysis was used with inductive and deductive approaches. RESULTS: In total 26 patients participated distributed over three focus groups, and 215 caregivers (104 rheumatologists, 111 general practitioners) filled out the survey. Both patients and caregivers endorse the need for early referral, and recognize the perceived benefit of the digital algorithm. Potential barriers include the complexity of currently included questions, and the outcome lacking information on what to do with no risk of IRD. In order for implementation to be successful, the inclusivity, accessibility, content and outcome of the algorithm are considered important themes. CONCLUSION: Successful implementation of a digital referral algorithm needs a systematic multi-facetted approach, considering the barriers and facilitators for implementation as discussed. Since the majority of identified barriers and facilitators was overlapping between all stakeholders, findings from this study can reliably inform further decision strategies for successful implementation.

Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias.

Importance: Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare's mandatory bundled payment reform-the Comprehensive Care for Joint Replacement (CJR) model-was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective: To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design Setting and Participants: This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures: Implementation of the CJR model in 2016. Main Outcomes and Measures: Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results: The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, -0.13 to -0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, -0.12 to -0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, -0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: -0.03, 95% CI, -0.09 to 0.02; P = .27). Conclusions and Relevance: In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.