Improving Quality of Care in Rheumatoid Arthritis Through Mobile Patient-Reported Outcome Measurement: Focus Group Study

Background: Patient-reported outcomes (PROs) for chronic disease management can be integrated into the routine workflow by leveraging mobile technology. Objective: The objective of our study was to describe the process of our quality improvement (QI) efforts using tablets for PRO collection in a busy, academic rheumatology practice to support a treat-to-target (TTT) approach for rheumatoid arthritis (RA) management. Methods: Our QI team designed a process for routine collection of PROs for RA patients at the Arthritis Center, employing information technology and an electronic medical record (EMR) system. Patients received a tablet at the clinic check-in desk to complete the Routine Assessment of Patient Index Data 3 (RAPID3) survey, a validated RA PRO. RAPID3 scores were uploaded to the EMR in real time and available for use in shared decision making during routine office visits. Weekly data were collected on RAPID3 completion rates and shared with front desk staff and medical assistants to drive improvement. Patients in our patient family advisory council and focus groups provided informal feedback on the process. Results: From May 1, 2017, to January 31, 2019, a total of 4233 RAPID3 surveys were completed by 1691 patients. The mean age of patients was 63 (SD 14) years; 84.00% (1420/1691) of the patients were female, and 83.00% (1403/1691) of the patients were white. The rates of RAPID3 completion increased from 14.3% (58/405) in May 2017 to 68.00% (254/376) in September 2017 and were sustained over time through January 2019. Informal feedback from patients was positive and negative, relating to the usability of the tablet and the way rheumatologists used and explained the RAPID3 data in shared decision making during the office visit. Conclusions: We designed a sustainable and reliable process for collecting PROs from patients with RA in the waiting room and integrated these data through the EMR during office visits

Identifying unrecognized peripheral arterial disease among asymptomatic patients in the primary care setting.

National initiatives to enhance recognition of the detrimental impact of peripheral arterial disease on the health of adult Americans have been advocated. The objective of this study was to evaluate a strategy for identifying patients with unrecognized peripheral arterial disease from among persons without known atherosclerotic disease in the primary care setting. A cross-sectional design was used. Participants were patients receiving care from a multispecialty group practice in Massachusetts between July 2002 and July 2003, with a scheduled appointment with a primary care physician. Persons 70 years of age or older who were not already known to have atherosclerotic disease were enrolled. In addition, persons aged 50-69 with a diagnosis of diabetes mellitus, dyslipidemia, hypertension, and/or smoking based on information derived from administrative databases, and not known to have atherosclerotic disease, were enrolled. Before the scheduled appointment, potential study participants completed a telephone interview to ascertain their medical history. The ankle-brachial index (ABI) of eligible patients was measured at the time of the scheduled primary care office visit. Peripheral arterial disease was diagnosed if 1 or both legs had an ABI of or=70 years, 45 (12.5%) were diagnosed with peripheral arterial disease. Nine (2.5%) of 358 subjects aged 50-69 years were diagnosed with peripheral arterial disease. The average total time (n = 52) for ABI testing was 13.7 (SD: +/-3.3) minutes. Patients aged \u3eor=70 years required more time for ABI testing compared to those aged 50-69 (mean: 15.0 vs 13.0 minutes, p=0.04). Unrecognized asymptomatic peripheral arterial disease can be commonly detected among patients in the primary care setting who are not already known to have atherosclerotic disease. The yield from screening is substantially greater among unselected older patients compared with younger patients specifically identified as having risk factors for PAD. These findings should help inform the development and implementation of new initiatives to enhance the early detection of peripheral arterial disease among asymptomatic patients in the primary care setting

Social amplification of risk: the media and public response

The risk associated with radioactive and other hazardous waste disposal may be expected to interact with societal processes to enlarge or attenuate the consequences of risks and events. Using a data base of 128 hazard events that have ocurred largely over the past ten years, the authors examine the role of physical consequences, media coverage, and public perceptions of risks in generating social and economic impacts. The analysis concludes that social amplification processes substantially shape the nature and magnitude of those impacts but also that such social amplification appears to be systematically relate to characteristics of the risks and risk events

Compliance with pharmacologic therapy for osteoporosis

There is little information available concerning compliance with pharmacologic therapy for osteoporosis in the usual care setting. We evaluated 176 consecutive, previously untreated women whose physicians initiated treatment for osteoporosis following a bone mineral density (BMD) test obtained as part of routine medical practice. All patients were contacted \u3e/=1 year after the initial BMD test and offered a follow-up BMD. Compliance with therapy was defined as the percent of time that a patient filled a prescription for osteoporosis treatment. Ninety-three (53%) patients received estrogen (ERT), 93 (53%) bisphosphonates, 8 (5%) calcitonin, and 17 (10%) received more than one therapy. Ninety-one of the 176 (52%) agreed to a follow-up BMD at a mean of 590 days after the first study (participants); 85 declined a follow-up BMD (refusers). Participants and refusers were similar for age, treatment patterns, and compliance with therapy. For all patients, compliance for those given bisphosphonate was similar to those given ERT (70.7% (95% CI 63.5-77.9%) versus 69.2% (95% CI 61.7-76.8%). For participants, the change in spine BMD was similar for those treated with bisphosphonate [mean increase 3.53 (+/-2.64)%/year (mean+/-SD)] and those treated with ERT [mean increase 3.00 (+/-2.75)%/year]. For those participants whose compliance with therapy was \u3e/=66%, the mean increase in spine bone density was 3.80 (+/-2.59)%/year compared to 2.11 (+/-2.64)%/year ( p\u3c0.005) for those whose compliance was \u3c66%. Compliance with ERT and bisphosphonate therapy initiated in routine practice after a BMD was similar over a mean of 590 days. Compliance less than 66% with drug treatment results in suboptimal improvement in bone density

Validation of a surveillance case definition for arthritis.

OBJECTIVE: To assess whether self-reports of chronic joint symptoms or doctor-diagnosed arthritis can validly identify persons with clinically verifiable arthritis. METHODS: The Behavioral Risk Factor Surveillance System (BRFSS), a telephone health survey, defines a case of arthritis as a self-report of chronic joint symptoms (CJS) and/or doctor-diagnosed arthritis (DDx). A sample of health plan enrollees aged 45-64 years and \u3e/= 65 years with upcoming annual physical examinations were surveyed by telephone using the 2002 BRFSS CJS and DDx questions. Based on responses (CJS+, DDx-; CJS-, DDx+; CJS+, DDx+; CJS-, DDx-), respondents were recruited to undergo a standardized clinical history and physical examination for arthritis (the gold standard for clinical validation). Weighted sensitivities and specificities of the case definition were calculated to adjust for sampling. RESULTS: Of 2180 persons completing the telephone questionnaire, 389 were examined; of these, 258 met the case definition and 131 did not. For those examined and aged 45 to 64 years (n = 179), 96 persons had arthritis confirmed, of whom 76 met the case definition. Among those examined and aged \u3e/= 65 (n = 210), 150 had arthritis confirmed, of whom 124 met the case definition. Among those without clinical arthritis, 45 of 83 of those aged 45 to 64 years and 40 of 60 of those aged \u3e/= 65 did not meet the case definition. For those aged 45 to 64 years, the weighted sensitivity of the case definition in this sample was 77.4% and the weighted specificity was 58.8%; for those aged \u3e/= 65, the sensitivity was 83.6% and specificity 70.6%. CJS+ had higher sensitivity and lower specificity than DDx+ in the younger age group; CJS+ and DDx+ behaved more comparably in the older age group. CONCLUSION: The case definition based on self-reported CJS and/or DDx appeared to be sensitive in identifying arthritis, but specificity was lower than desirable for those under age 65 years. Better methods of ascertaining arthritis by self-report are needed. Until then, a change in the surveillance case definition for arthritis appears warranted

Prevention of glucocorticoid-induced osteoporosis: experience in a managed care setting.

BACKGROUND: Treatment with glucocorticoids is the leading cause of drug-induced osteoporosis. Currently available guidelines indicate that patients receiving long-term glucocorticoid therapy should receive measures to prevent osteoporosis. OBJECTIVES: To examine whether patients receiving long-term glucocorticoid therapy in a managed care setting received preventive therapy or prescribed medications for osteoporosis and to identify patient and provider characteristics associated with treatment. SUBJECTS AND METHODS: A cohort of 224 health plan enrollees 20 years and older who were dispensed at least 1 oral glucocorticoid prescription per quarter during the period October 1997 through September 1998 was identified from administrative data. Medical charts and administrative data were reviewed to determine use of preventive therapy and prescribed medications for osteoporosis. RESULTS: Of the 224 patients, 62% had at least 1 documented intervention aimed at osteoporosis prevention (counseling about calcium or vitamin D or weight-bearing exercise; prescription for estrogen, calcitonin, or bisphosphonate; or a bone mineral density study). Women were more likely than men to receive intervention (76% vs 44%; prevalence odds ratio, 4.41; 95% confidence interval, 2.17-9.10). Patients receiving a mean daily prednisone dose of 10 mg or more or 5 to less than 10 mg were no more likely to receive intervention than those receiving 5 mg or less prednisone daily. Sixty-two (90%) of 69 patients who were prescribed glucocorticoid therapy by rheumatologists had at least 1 intervention documented compared with 29 (48%) of 60 for internists, 26 (55%) of 47 for pulmonologists, and 22 (46%) of 48 for all other physicians. In a multiple logistic regression model, including patient age, sex, mean daily glucocorticoid dose, and physician specialty, women and patients prescribed glucocorticoids by a rheumatologist were significantly more likely to receive intervention aimed at osteoporosis prevention. CONCLUSIONS: A substantial proportion of patients receiving long-term glucocorticoid therapy do not receive preventive therapy for osteoporosis. Efforts should be made to reduce barriers to such treatment and increase the proportion of patients given preventive therapy

Physicians’ Perceptions of and Satisfaction With Artificial Intelligence in Cancer Treatment: A Clinical Decision Support System Experience and Implications for Low-Middle–Income Countries

As technology continues to improve, health care systems have the opportunity to use a variety of innovative tools for decision-making, including artificial intelligence (AI) applications. However, there has been little research on the feasibility and efficacy of integrating AI systems into real-world clinical practice, especially from the perspectives of clinicians who use such tools. In this paper, we review physicians’ perceptions of and satisfaction with an AI tool, Watson for Oncology, which is used for the treatment of cancer. Watson for Oncology has been implemented in several different settings, including Brazil, China, India, South Korea, and Mexico. By focusing on the implementation of an AI-based clinical decision support system for oncology, we aim to demonstrate how AI can be both beneficial and challenging for cancer management globally and particularly for low-middle–income countries. By doing so, we hope to highlight the need for additional research on user experience and the unique social, cultural, and political barriers to the successful implementation of AI in low-middle–income countries for cancer care