Large language models and the future of rheumatology: assessing impact and emerging opportunities.

PURPOSE OF REVIEW: Large language models (LLMs) have grown rapidly in size and capabilities as more training data and compute power has become available. Since the release of ChatGPT in late 2022, there has been growing interest and exploration around potential applications of LLM technology. Numerous examples and pilot studies demonstrating the capabilities of these tools have emerged across several domains. For rheumatology professionals and patients, LLMs have the potential to transform current practices in medicine. RECENT FINDINGS: Recent studies have begun exploring capabilities of LLMs that can assist rheumatologists in clinical practice, research, and medical education, though applications are still emerging. In clinical settings, LLMs have shown promise in assist healthcare professionals enabling more personalized medicine or generating routine documentation like notes and letters. Challenges remain around integrating LLMs into clinical workflows, accuracy of the LLMs and ensuring patient data confidentiality. In research, early experiments demonstrate LLMs can offer analysis of datasets, with quality control as a critical piece. Lastly, LLMs could supplement medical education by providing personalized learning experiences and integration into established curriculums. SUMMARY: As these powerful tools continue evolving at a rapid pace, rheumatology professionals should stay informed on how they may impact the field.

Pharmacy technician development: Insight into training, preparedness, and career-path perceptions.

BACKGROUND: Although opportunities for pharmacy technicians may be expanding, an increasing number of technicians have transitioned out of their roles. It is important to consider what could be done within education and training to promote the retention of pharmacy technicians. OBJECTIVES: The purpose of this study was to survey pharmacy technicians in the state of Ohio to identify key components of professional development. METHODS: A survey was distributed through REDCap to 24,444 pharmacy technicians with active pharmacy technician licenses in the state of Ohio. Inclusion criteria required survey respondents to be at least 18 years old and currently working as a pharmacy technician. RESULTS: A total of 1386 surveys were fully completed (approximately 6% response rate). Professional development opportunities provided by employers varied across most practice sites, but continuing education was the most reported opportunity. Attending conferences, taking specialized training courses, and tuition reimbursement were less common. The top 3 barriers to professional development participation included additional cost, time, and perceived value. Guidance and mentorship from peers, achieving national certification, and formal on-the-job training were the most helpful in job preparation and training. The main reasons to achieve certification included increased pay, development opportunity, or employer requirement. When considering preparation for new roles, 57% of pharmacy technicians felt prepared or very prepared for the job after 90 days. As technicians continued throughout their careers, the training transitioned from formal hands-on training to self-guided training. CONCLUSION: Pharmacy technicians have a desire to remain in their roles, but participation in professional development opportunities was lacking owing to availability of options and barriers. Pharmacy practice sites interested in retaining technicians should invest in offering and encouraging pharmacy technicians to participate in development opportunities. To continue to develop pharmacy technicians, ongoing education and training tied to increased compensation may improve retention and foster an improved learning environment.

Periprosthetic Joint Infection in Patients With Inflammatory Arthritis: Optimal Tests to Differentiate From Flares.

OBJECTIVE: Diagnosis of periprosthetic joint infection (PJI) in patients with inflammatory arthritis (IA) is challenging, as features of IA flares can mimic infection. We aimed to cross-sectionally determine if the optimal tests to diagnose PJI in osteoarthritis were present in patients with IA flares. METHODS: We enrolled patients from October 2020 to July 2022 in 3 groups: (a) PJI-total joint arthroplasty patients undergoing revision for infection, (b) IA Flare-IA patients with a flaring native joint, and (c) IA Aseptic-total joint arthroplasty patients with IA undergoing aseptic arthroplasty revision. We compared blood and synovial fluid markers between the cohorts using Kruskal-Wallis and Fisher exact tests to assess marker sensitivity and specificity. RESULTS: Of 52 cases overall, 40% had rheumatoid arthritis, 20% psoriatic arthritis, and 11% osteoarthritis (in PJI group). PJI cases had higher C-reactive protein (CRP) and synovial fluid polymorphonuclear neutrophil percentage (%PMN). Alpha-defensin tested positive in 93% of PJI cases, 20% of IA Flares, and 6% of IA Aseptic (p < 0.01). Synovial white blood cell count >3000/µL and positive alpha-defensin were highly sensitive (100%) in diagnosing infection; however, specificity was 50% for white blood cell counts and 79% for alpha-defensin. PJI diagnosis was nearly 5 times more likely with positive alpha-defensin and almost 6 times more likely with %PMNs >80. Blood markers interleukin-6, procalcitonin, and d-dimer were neither sensitive nor specific, whereas erythrocyte sedimentation rate and CRP showed 80% sensitivity, but 47% and 58% respective specificities. CONCLUSIONS: Although synovial %PMNs, CRP, and alpha-defensin are sensitive tests for diagnosing PJI, they are less specific and may be positive in IA flares.

Comparing Medication History Capture Rates In-Person Versus Hybrid: A Multisite Pilot Study.

Purpose: Medication history is the method many organizations use to adhere to The Joint Commission's (TJC) National Patient Safety Goal (NPSG) to communicate accurate patient medication information. Literature is sparse comparing the number of medication histories completed in-person versus virtually. Methods: This is a single system, multi-site, retrospective observational study. Patients included were admitted through the Emergency Department during October 2022. The primary aim of this study compared the percent capture rates of medication history between 2 hybrid sites to an in-person site within a health-system. Our secondary objective compared the differences in the 'medication history acuity score' (MHAS), defined as the total number of edits, additions, and deletions made during a medication history. Results: The medication history capture rate at the in-person site was 74% and at the hybrid sites were 91% and 80%. There were no differences in total medications on each medication history between in-person and hybrid (11 [5-16] vs 11 [6-16]; P = .252). There were no differences in changes made on medication histories between in-person and hybrid (4 [1-7] vs 3 [1-7]; P = .595). Conclusions: Our study demonstrates that medication history capture rates and MHAS are comparable in both in-person and hybrid environments. This similarity suggests the feasibility of implementing hybrid models for medication history services in diverse healthcare settings, potentially enhancing the capacity of health systems to meet TJC NPSG. These findings indicate that hybrid models could be an effective strategy for healthcare systems to optimize their medication history services, especially in settings with varied patient volumes and site specialties.

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

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

Black Patients are More Likely to Undergo Early Revision Total Knee Arthroplasty in a Matched Cohort Regardless of Surgeon Experience.

BACKGROUND: Black patients are at an increased risk of aseptic revision total knee arthroplasty (TKA) when compared to White patients. The goal of this study was to determine whether racial disparities in revision TKA risk are related to surgeon characteristics. METHODS: This was an observational cohort study. We used inpatient administrative data to identify Black patients who underwent unilateral primary TKA in New York State. There were 21,948 Black patients who were matched 1:1 to White patients on age, sex, ethnicity, and insurance type. The primary outcome was aseptic revision TKA within 2 years of primary TKA. We calculated annual surgeon TKA volume and identified surgeon characteristics such as training in North America, board certification, and years of experience. RESULTS: Black patients had a higher odds of aseptic revision TKA (odds ratio (OR) 1.32, 95% CI 1.12-1.54, P < .001) and were disproportionately cared for by low volume surgeons (≤12 TKA/year). The relationship between low volume surgeons and risk of aseptic revision was not statistically significant (OR 1.24, 95% CI 0.72-2.11, P = .436). The adjusted odds ratio (aOR) for aseptic revision TKA in Black versus White patients varied across surgeon/hospital TKA volume category pairs, with the greatest aOR when TKA were performed by the highest volume surgeons at the highest volume hospitals (aOR 2.8, 95% CI 0.98- 8.09, P = .055). CONCLUSION: Black patients were more likely to undergo aseptic TKA revision than matched White patients. This disparity was not explained by surgeon characteristics.

Tumors Constitute a Majority of Total Knee Arthroplasty in Patients <21 Years Old: A United States Nationwide Analysis.

BACKGROUND: Total knee arthroplasty (TKA) is rarely performed in patients under 21 years old, but the frequency of utilization of TKA in this population in the United States is not known. The purpose of this study was to evaluate trends in the use of TKA in patients <21 in the United States. Additionally, we aimed to determine the characteristics of these patients and the hospitals in which this procedure is performed. METHODS: We retrospectively reviewed the Kids' Inpatient Database, a national weighted sample of all inpatient hospital admissions in the United States in patients <21 years of age. We used International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes to identify patients undergoing TKA from 2000 to 2019 and determine a primary diagnosis. Descriptive statistics were calculated using the appropriate sample weights. RESULTS: The total weighted number of TKAs performed in patients <21 years from 2000 to 2019 was 1,535. There were 70.9% of TKAs performed for a primary diagnosis of tumor, and the use of TKA for malignant tumors has increased. In contrast, the use of TKA for inflammatory arthritis/juvenile idiopathic arthritis decreased significantly over the study period. The majority of TKAs were performed in urban teaching hospitals with a large bed size. CONCLUSION: Approximately 1,535 TKAs have been performed in patients <21 years from 2000 to 2019 in the United States. The majority of these procedures were performed for reconstruction after resection of a malignant tumor. The rate of TKA for inflammatory arthritis/juvenile idiopathic arthritis has decreased over the past two decades.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective.

OBJECTIVE: To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS: We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS: The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION: This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Are Income-based Differences in TKA Use and Outcomes Reduced in a Single-payer System? A Large-database Comparison of the United States and Canada.

BACKGROUND: Income-based differences in the use of and outcomes in TKA have been studied; however, it is not known if different healthcare systems affect this relationship. Although Canada's single-payer healthcare system is assumed to attenuate the wealth-based differences in TKA use observed in the United States, empirical cross-border comparisons are lacking. QUESTIONS/PURPOSES: (1) Does TKA use differ between Pennsylvania, USA, and Ontario, Canada? (2) Are income-based disparities in TKA use larger in Pennsylvania or Ontario? (3) Are TKA outcomes (90-day mortality, 90-day readmission, and 1-year revision rates) different between Pennsylvania and Ontario? (4) Are income-based disparities in TKA outcomes larger in Pennsylvania or Ontario? METHODS: We identified all patients hospitalized for primary TKA in this cross-border retrospective analysis, using administrative data for 2012 to 2018, and we found a total of 161,244 primary TKAs in Ontario and 208,016 TKAs in Pennsylvania. We used data from the Pennsylvania Health Care Cost Containment Council, Harrisburg, PA, USA, and the ICES (formally the Institute for Clinical Evaluative Sciences), Toronto, Ontario, Canada. We linked patient-level data to the respective census data to determine community-level income using ZIP Code or postal code of residence and stratified patients into neighborhood income quintiles. We compared TKA use (age and gender, standardized per 10,000 population per year) for patients residing in the highest-income versus the lowest-income quintile neighborhoods. Similarly secondary outcomes 90-day mortality, 90-day readmission, and 1-year revision rates were compared between the two regions and analyzed by income groups. RESULTS: TKA use was higher in Pennsylvania than in Ontario overall and for all income quintiles (lowest income quartile: 31 versus 18 procedures per 10,000 population per year; p < 0.001; highest income quartile: 38 versus 23 procedures per 10,000 population per year; p < 0.001). The relative difference in use between the highest-income and lowest-income quintile was larger in Ontario (28% higher) than in Pennsylvania (23% higher); p < 0.001. Patients receiving TKA in Pennsylvania were more likely to be readmitted within 90 days and were more likely to undergo revision within the first year than patients in Ontario, but there was no difference in mortality at 1 year. When comparing income groups, there were no differences between the countries in 90-day mortality, readmission, or 1-year revision rates (p > 0.05). CONCLUSION: These results suggest that universal health insurance through a single-payer may not reduce the income-based differences in TKA access that are known to exist in the United States. Future studies are needed determine if our results are consistent across other geographic regions and other surgical procedures. LEVEL OF EVIDENCE: Level III, therapeutic study.

Satisfaction With the Process vs Outcome of Care in Total Hip and Knee Arthroplasty.

BACKGROUND: Patient satisfaction, with both process of care and outcome of care, is critical for measuring the quality and value of elective procedures such as arthroplasty. The purpose of this study is to evaluate the correlation between early postoperative satisfaction with the process of care and 2-year satisfaction with the outcome of care after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We retrospectively analyzed data from institutional arthroplasty registries. Satisfaction with the outcome of care was measured on a scale of 0-100 by a previously validated questionnaire administered 2 years postoperatively. Patient satisfaction with the process of care was measured by the Press Ganey (PG) inpatient survey, also scored 0-100. We examined the correlation between these 2 measures of satisfaction in patients who underwent primary THA or TKA. RESULTS: In total, 721 TKA patients and 760 THA patients underwent surgery and completed both the PG survey and 2-year satisfaction questionnaire. The mean age was 65.1 years with a mean body mass index of 28.8 and 56% were female. The mean PG survey score for the entire cohort was 95.6. The mean 2-year satisfaction score was 90.3. The Spearman correlation coefficient between the PG survey and the 2-year satisfaction survey was 0.23 for TKA patients (P < .001) and 0.13 for THA patients (P < .001). CONCLUSION: We found a weak correlation between the measurement of satisfaction with the process of care surrounding hip and knee arthroplasty using the PG survey and measurement of satisfaction with the outcome of care after arthroplasty using a validated 2-year satisfaction instrument.

Bilateral vs Unilateral Total Knee Arthroplasty: Racial Variation in Utilization and In-Hospital Major Complication Rates.

BACKGROUND: We sought to examine bilateral total knee arthroplasty (BTKA) vs unilateral TKA (UTKA) utilization and in-hospital complications comparing African Americans (AAs) and Whites. METHODS: In this retrospective analysis of patients ≥50 years who underwent elective primary TKA, the (2007-2016) database of the Healthcare Cost and Utilization Project (National Inpatient Sample) was used. We computed differences in temporal trends in utilization and major in-hospital complication rates of BTKA vs UTKA comparing AAs and Whites. We performed multivariable logistic regression models to assess racial differences in trends adjusting for individual-, hospital- and community-level variables. Discharge weights were used to enable nationwide estimates. We used multiple imputation procedures to impute values for 12% missing race information. RESULTS: An estimated 276,194 BTKA and 5,528,429 UTKA were performed in the US. The proportion of BTKA among all TKAs declined, and AAs were significantly less likely to undergo BTKA compared to Whites throughout the study period (trend P = .01). In-hospital complication rates for UTKA were higher in AAs compared to Whites throughout the study period (trend P < .0001). However, for BTKA, the in-hospital complication rates varied between Whites and AAs throughout the study period (trend P = .09). CONCLUSION: In this nationwide sample of patients who underwent total knee arthroplasty from 2007 to 2016, the utilization of BTKA was higher in Whites compared to AAs. On the other hand, while AAs have consistently higher in-hospital complication rates in UTKA over the time period, this pattern was not consistent for BTKA.

Use of Total Hip Arthroplasty in Patients Under 21 Years Old: A US Population Analysis.

BACKGROUND: The purpose of this study is to evaluate trends in the use of total hip arthroplasty (THA) in the United States in patients under 21 years of age. Specifically, we examined the frequency of THA in this patient population over the past 2 decades, the epidemiologic characteristics of patients under 21 who underwent THA, and the characteristics of the hospitals where these procedures were performed. METHODS: We retrospectively reviewed the Kids' Inpatient Database, an inpatient US national weighted sample of hospital admissions in patients under 21 from approximately 4200 hospitals in 46 states. We queried the database using Current Procedural Terminology codes for elective and non-elective primary THA for the years 2000-2016. We utilized the International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes to determine primary diagnoses. RESULTS: The weighted total number of THAs performed in patients under 21 in the Kids' Inpatient Database increased from 347 in 2000 to 551 in 2016. The most common diagnoses were osteonecrosis, osteoarthritis, and inflammatory arthritis. The frequency of THA for osteonecrosis increased from 24% in 2000 to 38% in 2016, while the frequency of THA for inflammatory arthritis decreased from 27% in 2000 to 4% in 2016. CONCLUSION: The number of THAs in patients under 21 in the United States has increased over the past 2 decades and these procedures are increasingly performed in urban teaching hospitals. The decrease in THA for inflammatory arthritis in this population likely reflects improvements in medical management during the study period.

Variables Associated With Perceived Risk of Contracting SARS-CoV-2 Infection During the COVID-19 Pandemic Among Patients With Systemic Rheumatic Diseases.

OBJECTIVE: The aim of this study was to assess patients' perceived risk of contracting SARS-CoV-2 at the peak of the pandemic in NYC in terms of their systemic rheumatic disease and medications. METHODS: With the approval of their rheumatologists, patients were interviewed by telephone and were asked about their perceived risk of contracting SARS-CoV-2 considering their rheumatic condition and whether medications increased this risk. Patients also completed surveys assessing beliefs about medication and multidimensions of physical/mental well-being. Information about current medications and rheumatologist-initiated changes in medications during the pandemic were reported by patients and verified from medical records. RESULTS: One hundred twelve patients (86% women; mean age, 50 years; 81% White, 15% Latino) with diverse diagnoses were enrolled. Fifty-four percent thought they were at "very much greater risk" of COVID-19 because of their rheumatic condition, and 57% thought medications "definitely" put them at greater risk. In multivariable analysis, the perception of "very much greater risk" was associated with greater belief that rheumatic disease medications were necessary, worse physical function, chronic pulmonary comorbidity, and more anxiety. In a separate model, the perception that medications "definitely" caused greater risk was associated with White race, not taking hydroxychloroquine, rheumatologists initiating change in medications, more anxiety, and taking biologics and corticosteroids. CONCLUSIONS: Patients' perceived increased risk of contracting SARS-CoV-2 was associated with beliefs about their rheumatic disease, medications, comorbidity, and anxiety. Clinicians should be aware of patients' perceptions and foster self-management practices that will alleviate anxiety, minimize exposure to the virus, and optimize systemic rheumatic disease outcomes.

Trends in Maternal and Fetal Outcomes Among Pregnant Women With Systemic Lupus Erythematosus in the United States: A Cross-sectional Analysis.

Background: Although pregnancy in systemic lupus erythematosus (SLE) carries a high risk for mother and fetus, outcomes may be improving. Objective: To assess nationwide trends and disparities in maternal and fetal complications among pregnant women with SLE. Design: Retrospective cohort study. Setting: United States, 1998 to 2015. Patients: Adult pregnant women with and without SLE who had hospitalizations recorded in the National Inpatient Sample (NIS) database. Measurements: Outcome measures were in-hospital maternal mortality, fetal mortality, preeclampsia or eclampsia, caesarean sections, non-delivery-related admissions, and length of stay. To assess whether trends in outcomes over time differed between patients with SLE and those without SLE, logistic or linear regression with an interaction term between year and SLE (yes or no) was used. Nationwide population estimates incorporating sampling and poststratification weights were obtained. Results: An estimated 93 820 pregnant women with SLE and 78 045 054 without SLE were hospitalized in the United States from 1998 through 2015. Outcomes improved during those 18 years. In-hospital maternal deaths (per 100 000 admissions) declined among patients with as well as those without SLE (442 vs. 13 for 1998 to 2000 and <50 vs. 10 for 2013 to 2015), although the decrease was greater in women with SLE (difference in trends, P < 0.002). The percentage of patients with SLE in all pregnancy-related, as well as delivery-related, admissions increased significantly. Limitations: The sample for this analysis was identified by using diagnostic codes; detailed information on hospital-specific trends, SLE disease activity, and medications was not available. Race trends could not be analyzed. Given that NIS uses weighted estimates, the incidence of outcomes reported may not be exact. Conclusion: In this large study examining SLE and non-SLE pregnancies over 18 years, in-hospital maternal mortality and overall outcomes improved markedly, particularly among women with SLE. However, improvement is still needed, because SLE pregnancy risks remain high. Primary Funding Source: None.

Assessment of a Satisfaction Measure for Use After Primary Total Joint Arthroplasty.

BACKGROUND: Patient satisfaction after total hip (THA) and total knee arthroplasty (TKA) is a core outcome selected by the Outcomes Measurement in Rheumatology. Up to 20% of THA/TKA patients are dissatisfied. Improving patient satisfaction is hindered by the lack of a validated measurement tool that can accurately measure change. METHODS: The psychometric properties of a proposed satisfaction instrument, consisting of 4 questions rated on a Likert scale, scored 1-100, were tested for validity, reliability, and sensitivity to change using data collected between 2007 and 2011 in an arthroplasty registry. RESULTS: We demonstrated construct validity by confirming our hypothesis; satisfaction correlated with similar constructs. Satisfaction correlated moderately with pain relief (TKA ρ = 0.61, THA ρ = 0.47) and function (TKA ρ = 0.65, THA ρ = 0.51) at 2 years; there was no correlation with baseline/preoperative pain/function values, as expected. Overall Cronbach's alpha >0.88 confirmed internal consistency. Test-retest reliability with weighted kappa ranged 0.60-0.75 for TKA and 0.36-0.56 for THA. Hip disability and Osteoarthritis Outcome Score/Knee injury and Osteoarthritis Outcome Scores quality of life improvement (>30 points) corresponds to a mean satisfaction score of 93.2 (standard deviation, 11.5) after THA and 90.4 (standard deviation, 13.8) after TKA, and increasing relief of pain and functional improvement increased the strength of their association with satisfaction. The satisfaction measure has no copyright and is available free of cost and represents minimal responder burden. CONCLUSION: Patient satisfaction with THA/TKA can be measured with a validated 4-item questionnaire. This satisfaction measure can be included in a total joint arthroplasty core measurement set for total joint arthroplasty trials.

Validation of the Hip Disability and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score Pain and Function Subscales for Use in Total Hip Replacement and Total Knee Replacement Clinical Trials.

BACKGROUND: Total hip replacement (THR)/total knee replacement (TKR) studies do not uniformly measure patient centered domains, pain, and function. We aim to validate existing measures of pain and function within subscales of standard instruments to facilitate measurement. METHODS: We evaluated baseline and 2-year pain and function for THR and TKR using Hip disability and Osteoarthritis Outcome Score (HOOS)/Knee Injury and Osteoarthritis Outcome Score (KOOS), with primary unilateral TKR (4796) and THR (4801). Construct validity was assessed by correlating HOOS/KOOS pain and activities of daily living (ADL), function quality of life (QOL), and satisfaction using Spearman correlation coefficients. Patient relevant thresholds for change in pain and function were anchored to improvement in QOL; minimally clinically important difference (MCID) corresponded to "a little improvement" and a really important difference (RID) to a "moderate improvement." Pain and ADL function scores were compared by quartiles using Kruskal-Wallis. RESULTS: Two-year HOOS/KOOS pain and ADL function correlated with health-related QOL (KOOS pain and Short Form 12 Physical Component Scale ρ = 0.54; function ρ = 0.63). Comparing QOL by pain and function quartiles, the highest levels of pain relief and function were associated with the most improved QOL. MCID for pain was estimated at ≥20, and the RID ≥29; MCID for function ≥14, and the RID ≥23. The measures were responsive to change with large effect sizes (≥1.8). CONCLUSION: We confirm that HOOS/KOOS pain and ADL function subscales are valid measures of critical patient centered domains after THR/TKR, and achievable thresholds anchored to improved QOL. Cost-free availability and brevity makes them feasible, to be used in a core measurement set in total joint replacement trials.

Hydroxychloroquine and Chloroquine in COVID-19: A Survey of Prescription Patterns Among Rheumatologists.

OBJECTIVE: With hydroxychloroquine (HCQ) and chloroquine (CQ) emerging as potential therapies for coronavirus disease 2019 (COVID-19), shortages have been reported. We aimed to understand how rheumatologists, one of the most common prescribers of HCQ/CQ, prescribed these medications to manage COVID-19 and to understand if their patients are affected by shortages. METHODS: Between April 8 and April 27, 2020, an online survey was distributed to a convenience sample of rheumatologists who practice medicine in a diverse range of settings globally, resulting in 506 responses. Adjusted Poisson regression models were calculated. RESULTS: Only 6% of respondents prescribed HCQ/CQ for COVID-19 prophylaxis, and only 12% for outpatient treatment of COVID-19. Compared to the United States, the likelihood of prescribing HCQ/CQ for prophylaxis was higher in India (adjusted risk ratio [aRR], 6.7; 95% confidence interval [CI], 2.7-16.8; p < 0.001). Further, compared to the United States and those with 1 to 5 years of experience, rheumatologists in Europe (aRR, 2.9; 95% CI, 1.6-5.3; p < 0.001) and those with 10+ years of experience (11-20 years: aRR, 2.5; 95% CI, 1.2-5.3; p = 0.015; 21+ years: aRR = 3.3; 95% CI, 1.4-7.4; p = 0.004) had a higher likelihood of prescribing HCQ/CQ for outpatient treatment. Of note, 71% of all rheumatologists reported that their patients were directly affected by HCQ/CQ shortages. CONCLUSION: The results suggest that only a small percentage of rheumatologists are prescribing HCQ/CQ for prophylaxis or outpatient treatment of COVID-19. Medication shortages experienced by large numbers of autoimmune disease patients are concerning and should play a role in decisions, especially given poor efficacy data for HCQ/CQ in COVID-19.

Living in immigrant communities does not impact total knee arthroplasty outcomes: experience from a high-volume center in the United States.

BACKGROUND: Community characteristics such as poverty affect total knee arthroplasty (TKA) outcomes. However, it is unknown whether other community factors such as immigrant proportion (IP) also affect outcomes. Our objective was to determine the association of neighborhood IP on preoperative (pre-op) and 2-year postoperative (post-op) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function after elective TKA. METHODS: Patients in a high volume institutional TKA registry between May 2007 and February 2011 were retrospectively analyzed. Demographics, pre-op and 2-year post-op WOMAC pain and function scores, and geocodable addresses were obtained. Patient-level variables were linked to US Census Bureau census tract data. The effect of patient and neighborhood-level factors on WOMAC scores were analyzed using linear mixed effects models. RESULTS: 3898 TKA patients were analyzed. Pre-op and 2-year post-op WOMAC pain and function scores were between 2.75-4.88 WOMAC points worse in neighborhoods with a high IP (≥ 40%) compared to low IP (< 10%). In multivariable analyses, these differences were not statistically significant. Women had worse pre-op and 2-year post-op WOMAC scores (all p ≤ 0.04), but this difference was not influenced by neighborhood IP (all pinteraction NS). CONCLUSIONS: Patients living in high (≥40%) IP neighborhoods do not have worse pre-op or 2-year post-op pain and function outcomes after TKA compared to those living in low (< 10%) IP neighborhoods. Although sex differences favoring males are notable, these differences are not associated with IP. High neighborhood IP do not appear to affect outcomes after TKA.

A structured patient identification model for medication therapy management services in a community pharmacy.

OBJECTIVES: To describe the development and implementation of a structured patient identification model for medication therapy management (MTM) services within traditional dispensing activities of a community pharmacy to facilitate pharmacist-provided completion of MTM services. DESIGN: A daily clinical opportunity report was developed as a structured model to identify MTM opportunities daily for all MTM-eligible patients expecting to pick up a prescription. Pharmacy staff was trained and the standardized model was implemented at study sites. SETTING AND PARTICIPANTS: One hundred nineteen grocery store-based community pharmacies throughout Ohio, West Virginia, and Michigan. OUTCOME MEASURES: A structured patient identification model in a community pharmacy consists of reviewing a clinical opportunity report, identifying interventions for MTM-eligible patients, and possibly collaborating with an interdisciplinary team. This model allows pharmacists to increase MTM cases performed by providing a structured process for identifying MTM-eligible patients and completing MTM services. RESULTS: The development and implementation of a structured patient identification model in the community pharmacy was completed and consists of pharmacists reviewing a clinical opportunity report to identify MTM opportunities and perform clinical interventions for patients. In a 3-month pre- and post-implementation comparison, there was a 49% increase in the number of MTM services provided by pharmacists (P < 0.001). CONCLUSION: A structured patient identification model in the community pharmacy was associated with an increase in the amount of MTM services provided by pharmacists. This method could be a useful tool at a variety of community pharmacies to solve challenges associated with MTM completion.