Principles of Justice, Equity, Diversity, and Inclusion in Health Care Distance Simulation Education: Consensus Building via the Nominal Group Technique.

PURPOSE: Health care distance simulation (HCDS) replicates professional encounters through an immersive experience overseen by experts and in which technological infrastructure enriches the learning activity. As HCDS has gained traction, so has the movement to provide inclusive and accessible simulation experiences for all participants. However, established guidelines for best practices in HCDS regarding justice, equity, diversity, and inclusion (JEDI) are lacking. This study aimed to generate consensus statements on JEDI principles in synchronous HCDS education using the nominal group technique (NGT). METHOD: Professionals with experience in HCDS education were invited to generate, record, discuss, and vote on ideas that they considered best practices for JEDI. This process was followed by a thematic analysis of the NGT discussion to provide a deeper understanding of the final consensus statements. An independent group of HCDS educators individually reviewed and recorded their agreement or disagreement with the consensus statements created by the NGT process. RESULTS: Eleven independent experts agreed on 6 key practices for JEDI in HCDS. Educators need to (1) be aware of JEDI principles, (2) be able to define and differentiate JEDI, (3) model JEDI in their environment, (4) have expertise and comfort facilitating conversations and debriefing around JEDI issues, (5) be advocates within their organizations to ensure equitable educational experiences, and (6) achieve JEDI without compromising educational objectives. Experts were divided on the approach to technology to ensure equitable learning experiences: some believed that the most basic technology accessible to all learners should be used, and some believed that the technology used should be determined by the competency of the students or faculty. CONCLUSIONS: Structural and institutional barriers in HCDS education persist despite agreement on key JEDI practices. Conclusive research is needed to guide the optimal policy in HCDS toward creating equitable learning experiences while bridging the digital divide.

Geographic Variation in Disease Burden and Mismatch in Care of Patients With Rheumatoid Arthritis in the United States.

OBJECTIVE: Our objective was to evaluate the factors associated with regional variation of rheumatoid arthritis (RA) disease burden in the US. METHODS: In a retrospective cohort analysis of Rheumatology Informatics System for Effectiveness (RISE) registry data, seropositivity, RA disease activity (Clinical Disease Activity Index [CDAI], Routine Assessment of Patient Index Data-version 3 [RAPID3]), socioeconomic status (SES), geographic region, health insurance type, and comorbidity burden were recorded. An Area Deprivation Index score of more than 80 defined low SES. Median travel distance to practice sites' zip codes was calculated. Linear regression was used to analyze associations between RA disease activity and comorbidity adjusting for age, sex, geographic region, race, and insurance type. RESULTS: Enrollment data for 184,722 patients with RA from 182 RISE sites were analyzed. Disease activity was higher in African American patients, in those from Southern regions, and in those with Medicaid or Medicare coverage. Greater comorbidity was prevalent in patients in the South and those with Medicare or Medicaid coverage. There was moderate correlation between comorbidity and disease activity (Pearson coefficient: RAPID3 0.28, CDAI 0.15). High-deprivation areas were mainly in the South. Less than 10% of all participating practices cared for more than 50% of all Medicaid recipients. Patients living more than 200 miles away from specialist care were located mainly in Southern and Western regions. CONCLUSION: A disproportionately large portion of socially deprived, high comorbidity, and Medicaid-covered patients with RA were cared for by a minority of rheumatology practices. Studies are needed in high-deprivation areas to establish more equitable distribution of specialty care for patients with RA.

Hydroxychloroquine and Risk of Long QT Syndrome in Rheumatoid Arthritis: A Veterans Cohort Study With Nineteen-Year Follow-up.

OBJECTIVE: Recent evidence suggests that hydroxychloroquine use is not associated with higher 1-year risk of long QT syndrome (LQTS) in patients with rheumatoid arthritis (RA). Less is known about its long-term risk, the examination of which was the objective of this study. METHODS: We conducted a propensity score-matched active-comparator safety study of hydroxychloroquine in 8,852 veterans (mean age 64 ± 12 years, 14% women, 28% Black) with newly diagnosed RA. A total of 4,426 patients started on hydroxychloroquine and 4,426 started on another nonbiologic disease-modifying antirheumatic drug (DMARD) and were balanced on 87 baseline characteristics. The primary outcome was LQTS during 19-year follow-up through December 31, 2019. RESULTS: Incident LQTS occurred in 4 (0.09%) and 5 (0.11%) patients in the hydroxychloroquine and other DMARD groups, respectively, during the first 2 years. Respective 5-year incidences were 17 (0.38%) and 6 (0.14%), representing 11 additional LQTS events in the hydroxychloroquine group (number needed to harm 403; [95% confidence interval (95% CI)], 217-1,740) and a 181% greater relative risk (95% CI 11%-613%; P = 0.030). Although overall 10-year risk remained significant (hazard ratio 2.17; 95% CI 1.13-4.18), only 5 extra LQTS occurred in hydroxychloroquine group over the next 5 years (years 6-10) and 1 over the next 9 years (years 11-19). There was no association with arrhythmia-related hospitalization or all-cause mortality. CONCLUSIONS: Hydroxychloroquine use had no association with LQTS during the first 2 years after initiation of therapy. There was a higher risk thereafter that became significant after 5 years of therapy. However, the 5-year absolute risk was very low, and the absolute risk difference was even lower. Both risks attenuated during longer follow-up. These findings provide evidence for long-term safety of hydroxychloroquine in patients with RA.

Associations of Cost Sharing With Rheumatoid Arthritis Disease Burden.

OBJECTIVE: To evaluate the regional variation of cost sharing and associations with rheumatoid arthritis (RA) disease burden in the US. METHODS: Patients with RA from rheumatology practices in Northeast, South, and West US regions were evaluated. Sociodemographics, RA disease status, and comorbidities were collected, and Rheumatic Disease Comorbidity Index (RDCI) score was calculated. Primary insurance types and copay for office visits (OVs) and medications were documented. Univariable pairwise differences between regions were conducted, and multivariable regression models were estimated to evaluate associations of RDCI with insurance, geographical region, and race. RESULTS: In a cohort of 402 predominantly female, White patients with RA, most received government versus private sponsored primary insurance (40% vs. 27.9%). Disease activity and RDCI were highest for patients in the South region, where copays for OVs were more frequently more than $25. Copays for OVs and medications were less than $10 in 45% and 31.8% of observations, respectively, and more prevalent in the Northeast and West patient subsets than in the South subset. Overall, RDCI score was significantly higher for OV copays less than $10 as well as for medication copays less than $25, both independent of region or race. Additionally, RDCI was significantly lower for privately insured than Medicare individuals (RDCI -0.78, 95% CI [-0.41 to -1.15], P < 0.001) and Medicaid (RDCI -0.83, 95% CI [-0.13 to -1.54], P = 0.020), independent of region and race. CONCLUSION: Cost sharing may not facilitate optimum care for patients with RA, especially in the Southern regions. More support may be required of government insurance plans to accommodate patients with RA with a high disease burden.

Cultural considerations in debriefing: a systematic review of the literature.

Background: Conversations are influenced by cultural perceptions, beliefs and values. Debriefing is a learning conversation. Without cross-cultural engagement or culturally relevant teaching, learning may be compromised and may result in an outcome opposite of that intended. Objective: This systematic review explores cultural considerations in healthcare simulation debriefing. We sought to explore findings that could help debriefers create culturally responsive and inclusive debriefings. Study selection: Studies were included if they were peer-reviewed articles in any language and focused on healthcare simulation debriefing and global cultural considerations. Research study methods included qualitative, quantitative or both. The review included any health-related profession and level of learner. Findings: Three studies met the criteria. The purposes of the three studies were significantly different and did not directly study cultural considerations in debriefing. Conclusions: The learner-educator relationship is at risk and learning may be negatively impacted without addressing cultural awareness. More studies are needed to fully describe the effect of culture on successful debriefing.

Chloroquine to fight COVID-19: A consideration of mechanisms and adverse effects?

The COVID-19 outbreak emerged in December 2019 and has rapidly become a global pandemic. A great deal of effort has been made to find effective drugs against this disease. Chloroquine (CQ) and hydroxychloroquine (HCQ) were widely adopted in treating COVID-19, but the results were contradictive. CQ/HCQ have been used to prevent and treat malaria and are efficacious anti-inflammatory agents in rheumatoid arthritis and systemic lupus erythematosus. These drugs have potential broad-spectrum antiviral properties, but the underlying mechanisms are speculative. In this review, we re-evaluated the treatment outcomes and current hypothesis for the working mechanisms of CQ/HCQ as COVID-19 therapy with a special focus on disruption of Ca2+ signaling. In so doing, we attempt to show how the different hypotheses for CQ/HCQ action on coronavirus may interact and reinforce each other. The potential toxicity is also noted due to its action on Ca2+ and hyperpolarization-activated cyclic nucleotide-gated channels in cardiac myocytes and neuronal cells. We propose that intracellular calcium homeostasis is an alternative mechanism for CQ/HCQ pharmacology, which should be considered when evaluating the risks and benefits of therapy in these patients and other perspective applications.

How to use biologic agents in patients with rheumatoid arthritis who have comorbid disease.

Although biologic disease modifying anti-rheumatic drugs (bDMARDs) have improved the quality of life of patients with rheumatoid arthritis, side effects remain a problem, especially for patients with pre-existing comorbidities. Randomized controlled trials of such drugs in rheumatoid arthritis typically exclude patients with comorbidities and are of short duration, so they do not provide data on adverse events in these people. Other data sources such as national bDMARD registries are limited by the preselection of patients for both conventional synthetic chemical compound disease modifying anti-rheumatic drugs (csDMARDs) and bDMARDs, and although these databases document comorbidity, they rarely report its severity. This too limits definitive statements on the progression or resolution of pre-existing disease. Although bDMARDs may not be contraindicated in patients with rheumatoid arthritis and certain comorbid diseases, additional assessments or precautions are recommended. This review summarizes current data on the use of bDMARDs in people with rheumatoid arthritis and common comorbid diseases. It provides an evidence base for doctors and their patients when discussing and selecting the appropriate bDMARDs.