Classifying Multimorbidity Using Drug Concepts via the Rx-Risk Comorbidity Index: Methods and Comparative Cross-Sectional Study.

OBJECTIVE: The study objective was to update a method to identify comorbid conditions using only medication information in circumstances in which diagnosis codes may be undercaptured, such as in single-specialty electronic health records (EHRs), and to compare the distribution of comorbidities across Rx-Risk versus other traditional comorbidity indices. METHODS: Using First Databank, RxNorm, and its web-based clients, RxNav and RxClass, we mapped Drug Concept Unique Identifiers (RxCUIs), National Drug Codes (NDCs), and Anatomical Therapeutic Chemical (ATC) codes to Rx-Risk, a medication-focused comorbidity index. In established rheumatoid arthritis (RA) and osteoarthritis (OA) cohorts within the Rheumatology Informatics System for Effectiveness registry, we then compared Rx-Risk with other comorbidity indices, including the Charlson Comorbidity Index, Rheumatic Disease Comorbidity Index (RDCI), and Elixhauser. RESULTS: We identified 965 unique ingredient RxCUIs representing the 46 Rx-Risk comorbidity categories. After excluding dosage form and ingredient related RxCUIs, 80,911 unique associated RxCUIs were mapped to the index. Additionally, 187,024 unique NDCs and 354 ATC codes were obtained and mapped to the index categories. When compared to traditional comorbidity indices in the RA cohort, the median score for Rx-Risk (median 6.00 [25th percentile 2, 75th percentile 9]) was much greater than for Charlson (median 0 [25th percentile 0, 75th percentile 0]), RDCI (median 0 [25th percentile 0, 75th percentile 0]), and Elixhauser (median 1 [25th percentile 1, 75th percentile 1]). Analyses of the OA cohort yielded similar results. For patients with a Charlson score of 0 (85% of total), both the RDCI and Elixhauser were close to 1, but the Rx-Risk score ranged from 0 to 16 or more. CONCLUSION: The misclassification and under-ascertainment of comorbidities in single-specialty EHRs can largely be overcome by using a medication-focused comorbidity index.

Telemedicine in rheumatology care: A systematic review.

OBJECTIVE: The COVID-19 pandemic led to a sudden uptake of telemedicine in rheumatology. We analyzed the recent published literature on telemedicine for the diagnosis and management of inflammatory, non-inflammatory and/or autoimmune rheumatic diseases. METHODS: We performed a registered systematic search (CRD42020202063) for interventional or observational studies published between August 2015 and January 2022. We included studies of telemedicine that reported outcomes (e.g., satisfaction, disease activity, quality of life) in ten or more people with rheumatic disease. Reviewers screened manuscripts, extracted data, and assessed bias. RESULTS: Of the 2,988 potentially eligible studies, 36 reports were included: 27 observational studies, 7 randomized clinical trials, and 2 controlled clinical trials. Studies focused on general rheumatology (n = 18), rheumatoid arthritis (n = 9), gout (n = 3), osteoarthritis (n = 2), unspecified inflammatory arthritis (n = 1), osteoporosis (n = 2), and systemic lupus erythematosus (n = 1). Patient satisfaction with telemedicine was the most common reported outcome (n = 23) with majority of studies demonstrating high levels of satisfaction. Among interventional studies, the effect of telemedicine on the primary outcomes varied, with most finding that telemedicine was as good as usual / in-person care for disease activity control, patient satisfaction, total societal costs, and other patient reported outcomes. Effectiveness and feasibility were high across studies, though most demonstrated a high risk of bias. Meta-analysis was not feasible given the heterogeneity of interventions and outcome instruments utilized. CONCLUSION: Although the number of studies to date is low, telemedicine may be an effective mode to deliver care for people with rheumatic diseases. Most studies demonstrated limitations due to study design and risk of bias. Randomized clinical studies are needed to determine best uses of telemedicine for the diagnosis and management of rheumatic conditions.

Evaluation of an Intervention to Support Patient-Rheumatologist Conversations About Escalating Treatment in Patients with Rheumatoid Arthritis: A Proof-of-Principle Study.

OBJECTIVE: This study's objective was to test whether an online video intervention discussing appropriate treatment escalation improves willingness to change treatment in people living with rheumatoid arthritis (RA). METHODS: We conducted a controlled, randomized trial among patients with RA enrolled in ArthritisPower, a United States patient registry. We recruited participants by email and surveyed their assessment of disease activity (patient global), satisfaction with disease control (patient acceptable symptom state), attitudes about RA medications, decisional conflict (decisional conflict scale), and willingness to modify RA treatment (choice predisposition scale, higher scores are better) if or when recommended by their rheumatologist. Intervention groups watched educational videos relevant to a treat-to-target (T2T) strategy, whereas control groups viewed vaccination-related videos as an "attention control." We compared the between-group difference in patients' willingness to modify RA treatment (primary outcome) and difference in decisional conflict about changing RA treatment (secondary outcome) after watching the videos using t tests. RESULTS: Participants with self-reported RA (n = 208) were 90% White and 90% women, with a mean (standard deviation) age of 50 (11) years, and 52% reported familiarity with the RA T2T strategy. We found a significant improvement in between-group difference in willingness to change RA treatment among intervention versus control participants (0.49 [95% confidence interval 0.09-0.88], P = 0.02). The effect size (Glass's delta) for the intervention was 0.48. Decisional conflict about treatment change decreased, but the between-group difference was not significant. CONCLUSION: This novel educational patient-directed intervention discussing appropriate treatment escalation was associated with improved willingness to change RA treatment if or when recommended by a rheumatologist. Further studies should evaluate whether this change in patients' predisposition translates into actual treatment escalation.

Frequency of Prescription Claims for Drugs that May Interact with Janus Kinase Inhibitors Among Patients with Rheumatoid Arthritis in the US.

INTRODUCTION: This study describes the frequency of prescription claims for drugs that may interact with Janus kinase (JAK) inhibitors among adult patients with rheumatoid arthritis (RA) in a large US claims database. METHODS: This observational, retrospective, cross-sectional study of the IBM® MarketScan® Research Commercial and the Medicare Supplemental Database included adults (≥ 18 years) with ≥ 2 outpatient claims 30 or more days apart or ≥ 1 inpatient visit claim with an RA diagnosis between January 1, 2013 and March 31, 2017 (the index period). During the study period, from January 1, 2013 to March 31, 2018, strong organic anion transporter (OAT3) inhibitors, strong cytochrome P450 (CYP) 3A4 inhibitors, and moderate or strong CYP3A4 inhibitors in combination with strong CYP2C19 inhibitors, were identified as drugs with potential for drug-drug interactions (DDIs) with JAK inhibitors approved for RA treatment in the US. Descriptive statistics were conducted. RESULTS: A total of 152,853 patients met eligibility criteria. Approximately 76% were women and the median age was 57 years. Of these patients, < 0.1% had a claim for a strong OAT3 inhibitor, and 1% had claims for the combination of a strong CYP3A4 and strong CYP2C19 inhibitor; 3% of patients had a claim for a strong CYP3A4 inhibitor and almost 10% had claims for both a moderate CYP3A4 and a strong CYP2C19 inhibitor. CONCLUSIONS: Up to 10% of RA patients have been prescribed a drug with a potential JAK interaction. Rheumatologists should consider potential DDIs when managing patients with RA.

Patient and Rheumatologist Perspectives Regarding Challenges to Achieving Optimal Disease Control in Rheumatoid Arthritis.

OBJECTIVE: To identify and prioritize patient- and rheumatologist-perceived barriers to achieving disease control. METHODS: Patients with rheumatoid arthritis (RA) and rheumatologists from the Corrona registry were invited by e-mail to participate in nominal groups. Two separate lists of barriers were created, 1 from RA patient-only nominal groups and the other from rheumatologist-only nominal groups, and barriers were sorted into themes. Next, using an online survey, a random sample of RA patients from the Corrona registry were asked to rank their top 3 barriers to achieving disease control. RESULTS: Four nominal groups totaling 37 RA patients identified patient barriers to achieving control of RA activity that were classified into 17 themes. Three nominal groups totaling 25 rheumatologists identified barriers that were classified into 11 themes. The financial aspects of RA care ranked first for both types of nominal groups, while medication risk aversion ranked second among the perceived barriers of the physician nominal group and third among those of the RA patient nominal group. Among the 450 RA patients surveyed, 77% considered RA a top health priority, and 51% reported being aware of the treat-to-target strategy for RA care; the 3 most important patient-perceived challenges to achieving disease control were RA prognosis uncertainty, medication risk aversion, and the financial/administrative burden associated with RA care. CONCLUSION: There are common, potentially modifiable, patient- and rheumatologist-reported barriers to achieving RA disease control, including perceived medication risk aversion, suboptimal treatment adherence, and suboptimal patient-physician communication regarding the benefits of tight control of disease activity in RA. Addressing these obstacles may improve adherence to goal-directed RA care.

Digital Tracking of Rheumatoid Arthritis Longitudinally (DIGITAL) Using Biosensor and Patient-Reported Outcome Data: Protocol for a Real-World Study.

BACKGROUND: Rheumatoid arthritis (RA) is a condition with symptoms that vary over time. The typical 3- to 6-month interval between physician visits may lead to patients failing to recall or underreporting symptoms experienced during the interim. Wearable digital technology enables the regular passive collection of patients' biometric and activity data. If it is shown to be strongly related to data captured by patient-reported outcome (PRO) measures, information collected passively from wearable digital technology could serve as an objective proxy or be complementary to patients' subjective experience of RA symptoms. OBJECTIVE: The goal of this study is to characterize the extent to which digital measures collected from a consumer-grade smartwatch agree with measures of RA disease activity and other PROs collected via a smartphone app. METHODS: This observational study will last 6 months for each participant. We aim to recruit 250 members of the ArthritisPower registry with an RA diagnosis who will receive a smartwatch to wear for the period of the study. From the ArthritisPower mobile app on their own smartphone device, participants will be prompted to answer daily and weekly electronic PRO (ePRO) measures for the first 3 months. RESULTS: The study was launched in December 2018 and will require up to 18 months to complete. Study results are expected to be published by the end of 2021. CONCLUSIONS: The completion of this study will provide important data regarding the following: (1) the relationship between passively collected digital measures related to activity, heart rate, and sleep collected from a smartwatch with ePROs related to pain, fatigue, physical function, and RA flare entered via smartphone app; (2) determine predictors of adherence with smartwatch and smartphone app technology; and (3) assess the effect of study-specific reminders on adherence with the smartwatch. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14665.

Uptake and Clinical Utility of Multibiomarker Disease Activity Testing in the United States.

OBJECTIVE: The clinical utility of the multibiomarker disease activity (MBDA) test for rheumatoid arthritis (RA) management in routine care in the United States has not been thoroughly studied. METHODS: Using 2011-2015 Medicare data, we linked each patient with RA to their MBDA test result. Initiation of a biologic or Janus kinase (JAK) inhibitor in the 6 months following MBDA testing was described. Multivariable adjustment evaluated the likelihood of adding or switching biologic/JAK inhibitor, controlling for potential confounders. For patients with high MBDA scores who added a new RA therapy and were subsequently retested, lack of improvement in the MBDA score was evaluated as a predictor of future RA medication failure, defined by the necessity to change RA medications again. RESULTS: Among 60,596 RA patients with MBDA testing, the proportion adding or switching biologics/JAK inhibitor among those not already taking a biologic/JAK inhibitor was 9.0% (low MBDA), 11.8% (moderate MBDA), and 19.7% (high MBDA, p < 0.0001). Similarly, among those already taking biologics/JAK inhibitor, the proportions were 5.2%, 8.3%, and 13.5% (p < 0.0001). After multivariable adjustment, referent to those with low disease MBDA scores, the likelihood of switching was 1.51-fold greater (95% CI 1.35-1.69) for patients with moderate MBDA scores, and 2.62 (2.26-3.05) for patients with high MBDA scores. Among those with high MBDA scores who subsequently added a biologic/JAK inhibitor and were retested, lack of improvement in the MBDA score category was associated with likelihood of future RA treatment failure (OR 1.61, 95% CI 1.27-2.03). CONCLUSION: The MBDA score was associated with both biologic and JAK inhibitor medication addition/switching and subsequent treatment outcomes.

Pharmacy students' perceptions of the usefulness of motivational interviewing and the use of mobile health applications on patient counseling in the future.

INTRODUCTION: To explore student pharmacists' perceptions of 1) future patient counseling, 2) use of mobile health applications (mHealth apps), and 3) usefulness of motivational interviewing (MI) in patient encounters and potential app messaging. METHODS: A cross-sectional design with first and second year pharmacy students (n=315) at a multi-campus university after exposure to mHealth app and MI curricular content. A questionnaire assessed perceptions of 1) future patient counseling, 2) using apps for personal use and professional encounters, and 3) potential practicality and usefulness of MI principles/skills in apps messaging. RESULTS: Over 70% of students perceived they will be counseling future patients for medication therapy/comprehensive disease management; 91% believed it is an important role as a future pharmacist. A majority own a smartphone (98%), have used an mHealth app to monitor/change a health behavior (73%), and are likely to recommend an mHealth app in future patient encounters (90%). Perceptions of counseling importance and likelihood to recommend an mHealth app varied by gender (women higher than men, p<0.01, p<0.01) and previous mHealth app use (yes higher than no, p<0.05, p<0.001). Most students reported a high likelihood of incorporating MI into current (88%) and future (91%) patient encounters and particularly noted 'supporting self-efficacy' as a useful MI principle to incorporate into mHealth app messaging. DISCUSSION AND CONCLUSIONS: Those using apps for personal health behavior change(s) perceived future patient counseling as important and were more likely to recommend mHealth apps during those future encounters. Results may inform curricular development to prepare future pharmacists for the high-tech, patient-centered practice that is inevitable.

Community pharmacy owners' views of star ratings and performance measurement: In-depth interviews.

OBJECTIVES: The star rating system implemented by Medicare has the potential to positively affect patient health and may have financial implications for community pharmacies. Learning from owners of community pharmacies with high performance on these quality measures may help us to identify and further understand factors contributing to their success. This study described high-performing community pharmacy owners' current awareness and knowledge of star ratings, attitudes toward star ratings and performance measurement, and initiatives being offered in pharmacies that aim to improve the quality of care. METHODS: Qualitative interviews with owners of independent community pharmacies were conducted in Spring 2015. Fifteen community pharmacies with high performance on the star rating measures were invited to participate. Recruitment did not end until the saturation point had been reached. All interviews were transcribed verbatim. Interview data were analyzed with the use of ATLAS.ti by 2 coders trained in thematic analysis. Krippendorf's alpha was calculated to assess intercoder reliability. RESULTS: Ten high-performing pharmacy owners participated. Analysis identified 8 themes, which were organized into the following categories: 1) current awareness and knowledge (i.e., superficial or advanced knowledge); 2) attitudes toward star ratings (positive perceptions, skeptical of performance rewards, and lack a feeling of control); and 3) pharmacy initiatives (personal patient relationships, collaborative employee relationships, and use of technology). Intercoder reliability was good overall. CONCLUSION: Interviews with high-performing pharmacies suggested that awareness of the star rating measures, overall positive attitudes toward the star ratings, the relationships that pharmacy owners have with their patients and their employees, and the use of technology as a tool to enhance patient care may contribute to high performance on the star rating measures. Future research is needed to determine if and how these constructs are associated with pharmacy performance in a larger population.

Impact of the RxVaccinate program for pharmacy-based pneumococcal immunization: A cluster-randomized controlled trial.

OBJECTIVES: To evaluate the impact of the RxVaccinate program on the structure, process, and outcome measures and to assess team leaders' perceptions of the program. DESIGN: Cluster-randomized experimental design. SETTING: Community pharmacies. PARTICIPANTS: Community pharmacists. INTERVENTIONS: The RxVaccinate program consisted of (a) two self-directed training webinars and practice development and implementation tools and (b) expert and peer coaching sessions through an in-person 4-hour workshop and optional e-community and monthly teleconferences. One group received only the self-directed training (self-directed learning group), and the other group received both self-directed training and coaching sessions (coaching group). MAIN OUTCOME MEASURES: Both groups provided data on (a) completion of structure and process indicators at 3, 6, and 9 months after the in-person workshop, (b) number of pneumococcal vaccinations administered in pharmacy during the 12-month period preceding and following the in-person coaching workshop, and (c) team leaders' perceptions of the RxVaccinate program. RESULTS: Greater proportions of pharmacies in the coaching group completed structure and process indicators than pharmacies in the self-directed learning group. Both groups showed an increase in the number of pneumococcal vaccinations administered (P < 0.001). The increase was significantly greater among pharmacies in the coaching group than among pharmacies in the self-directed training (P = 0.032). Team leaders in both groups were generally satisfied with the RxVaccinate program. CONCLUSION: Although significant increases in the number of pharmacist-administered pneumococcal vaccinations were observed in both groups, the increase was greater in the group receiving both self-directed training and expert and peer coaching than the group without the coaching strategy. This could be because pharmacies in the coaching group were more likely to complete structure and process indicators than their counterparts. Future studies should examine key structure and process indicators affecting the success of pneumococcal vaccinations.

Pilot Study to Test the Effectiveness of Different Financial Incentives to Improve Medication Adherence.

BACKGROUND: Medication nonadherence affects health care costs, morbidity, and mortality. Concepts from behavioral economics can guide the development of interventions to improve medication adherence. OBJECTIVE: To measure the relative effectiveness of 2 behavioral economic-based incentive structures to improve medication adherence. METHODS: This randomized controlled trial compared adherence among participants taking antihypertensive or antihyperlipidemic medications randomized to usual care (UC), guaranteed pay-out (GPO) incentives, or lottery incentives. Daily adherence was measured over a 90-day period using electronic caps (Medication Event Monitoring System [MEMS]). The GPO group received $30 up-front in a virtual account, with $0.50 deducted for each missed dose. Lottery group participants were eligible for a weekly $50 drawing, but only if they had taken their medication as prescribed all week. An electronic survey assessed self-reported adherence. Statistical analysis included descriptive statistics, paired t tests, ANOVA, and Pearson's correlations. RESULTS: In all, 36 participants were randomized (UC, n = 11; GPO, n = 14; lottery, n = 11). Mean percentage (±SD) of days adherent during the incentive period was highest in the lottery group (96% ± 5%), followed by the GPO group (94% ± 9%) and the UC group (94% ± 9%). There were no statistically significant differences among groups (P > 0.05). MEMS-measured adherence was not significantly correlated with a patient's self-reported adherence (P > 0.05) at baseline but was correlated at 90-day follow-up (P < 0.001). CONCLUSIONS: Although no statistically significant differences in adherence were demonstrated in this small sample of highly adherent participants, larger studies in a more diverse population or with other medications might show otherwise.

Impulsivity and Fast-Food Consumption: A Cross-Sectional Study among Working Adults.

BACKGROUND: Little is known about the decision-making process of adults who choose to eat at fast-food restaurants. Impulsivity is the concept that individuals value immediate rewards and disregard future costs. OBJECTIVE: To determine the association between impulsivity and consumption of fast food among employed adults and to explore their reasons for eating fast food. DESIGN: A cross-sectional, online survey was conducted; participants were recruited using a mass electronic mailing. PARTICIPANTS/SETTING: Four hundred seventy-eight adults employed in a university setting completed the survey. MAIN OUTCOME MEASURES: The association between frequency of fast-food consumption and impulsivity was assessed. Impulsivity is assessed by the area under the delay discounting curve (AUC). The AUC is estimated by using a binary choice delay discounting task incorporating hypothetical monetary rewards. Greater AUC reflects lower impulsivity. STATISTICAL ANALYSES PERFORMED: Analysis of variance, Student's t tests, and Pearson correlation coefficients were used to measure unadjusted associations among demographic variables, fast-food consumption, and AUC. Linear regression was used to assess whether AUC was a significant predictor of having consumed fast food in the past 7 days, controlling for age, total household income, and education. RESULTS: The majority (67%) of the participants reported eating one or more meals from a fast-food restaurant or pizza place in the past 7 days. The mean number of meals was 2.8±2.5 per week among those who reported eating at a fast-food restaurant or pizza place. Both fast-food consumption and body mass index (BMI) were correlated with greater impulsivity. Controlling for age, total household income, and education level, fast-food consumption was negatively related to AUC (P=0.017). The most commonly reported reasons for consuming fast food were convenience and to socialize. CONCLUSIONS: These findings indicate that greater impulsivity was associated with greater fast-food consumption. Successful efforts to encourage healthful dietary behaviors might emphasize methods to overcome impulsivity, such as reward substitution and precommitment.