Development of the American College of Rheumatology Electronic Clinical Quality Measures for Gout

Objective

Electronic clinical quality measures (eCQMs) are increasingly used by health registries and third parties to evaluate and improve the quality of health care. To complete these eCQMs, data are extracted from electronic health records (EHRs). The treatment of gout has been an area identified with gaps in quality of care. On behalf of the American College of Rheumatology (ACR), we sought to develop and test eCQMs to evaluate gout care.

Methods

Drawing from the 2012 ACR gout guidelines, a working group developed candidate gout process measures that were evaluated by an interdisciplinary panel of health care stakeholders, the ACR Quality Measures Subcommittee (QMS), and ultimately the ACR Board of Directors for formal validity testing. For each of the selected gout eCQMs, 3 clinical sites using different EHR systems tested the scientific feasibility and validity of the measures. Measures appropriate for accountability were presented for national endorsement.

Results

Of the 10 proposed eCQMs, 4 were endorsed by the ACR QMS, 3 were incorporated into the ACR's Rheumatology Informatics System for Effectiveness (RISE) Registry, and 2 were endorsed by the National Quality Forum. The 3 eCQMs incorporated into RISE (evaluating indications for urate‐lowering therapy [ULT]), monitoring serum urate, and treat‐to‐target outcome) demonstrated high validity and reliability. Proportions of patients passing these 3 eCQMs in RISE and at the 3 clinical testing sites ranged between 32% and 58%, indicating significant room for improvement in care.

Conclusion

Three eCQMs have been validated and implemented into RISE. Two of these measures (evaluating indications for ULT and monitoring serum urate) are available for use in federal quality reporting programs. Performance on these measures suggests there is significant room for improvement in the management of gout.

     

Role of the urate transporter SLC2A9 gene in susceptibility to gout in New Zealand Māori,Pacific Island,and Caucasian case–control sample sets

Objective

To examine the role of genetic variation in the renal urate transporter SLC2A9 in gout in New Zealand sample sets of Māori, Pacific Island, and Caucasian ancestry and to determine if the Māori and Pacific Island samples could be useful for fine‐mapping.

Methods

Patients (n= 56 Māori, 69 Pacific Island, and 131 Caucasian) were recruited from rheumatology outpatient clinics and satisfied the American College of Rheumatology criteria for gout. The control samples comprised 125 Māori subjects, 41 Pacific Island subjects, and 568 Caucasian subjects without arthritis. SLC2A9 single‐nucleotide polymorphisms rs16890979 (V253I), rs5028843, rs11942223, and rs12510549 were genotyped (possible etiologic variants in Caucasians).

Results

Association of the major allele of rs16890979, rs11942223, and rs5028843 with gout was observed in all sample sets (P = 3.7 × 10⁻⁷, 1.6 × 10⁻⁶, and 7.6 × 10⁻⁵ for rs11942223 in the Māori, Pacific Island, and Caucasian samples, respectively). One 4‐marker haplotype (1/1/2/1; more prevalent in the Māori and Pacific Island control samples) was not observed in a single gout case.

Conclusion

Our data confirm a role of SLC2A9 in gout susceptibility in a New Zealand Caucasian sample set, with the effect on risk (odds ratio >2.0) greater than previous estimates. We also demonstrate association of SLC2A9 with gout in samples of Māori and Pacific Island ancestry and a consistent pattern of haplotype association. The presence of both alleles of rs16890979 on susceptibility and protective haplotypes in the Māori and Pacific Island sample is evidence against a role for this nonsynonymous variant as the sole etiologic agent. More extensive linkage disequilibrium in Māori and Pacific Island samples suggests that Caucasian samples may be more useful for fine‐mapping.

     

Affect and Incident Participation Restriction in Adults With Knee Osteoarthritis

Objective

Participation restriction, common among people with knee osteoarthritis (OA), may be influenced by affect. We examined the risk of incident participation restriction over 84 months conferred by positive and negative affect among people with knee OA.

Methods

Participants were from the Multicenter Osteoarthritis Study and had or were at high risk of knee OA. Participation restriction was measured using the Instrumental Role Limitation subscale of the Late‐Life Disability Index, and affect was measured using the positive affect and depressed mood subscales of the Center for Epidemiologic Studies Depression Scale. Robust Poisson regression was used to calculate the risk of incident participation restriction over 84 months conferred by combinations of low and high positive and negative affect, adjusting for covariates.

Results

Of 1,810 baseline participants (mean age 62.1 years, 56% female), 470 (26%) had incident participation restriction over 84 months. Participants with low positive affect had 20% greater risk of incident participation restriction than those with high positive affect; participants with high negative affect had 50% greater risk of incident participation restriction compared to those with low negative affect. Participants with both low positive and high negative affect had 80% greater risk of incident participation restriction compared to other combinations of positive and negative affect.

Conclusion

Low positive and high negative affect, both alone and in combination, increase the risk of participation restriction among adults with knee OA. Efforts aimed at preventing participation restriction in this population should consider these mood states.

     

Supporting Arthritis and Employment Across the Life Course: A Qualitative Study

Objective

To examine the need for and availability and use of formal and informal workplace resources and to uncover differences across the life course in adults with arthritis.

Methods

Focus groups and interviews were conducted with young (aged 18–34 years; n = 7), middle‐aged (35–54 years; n = 13), and older adults (≥55 years; n = 25) with a diagnosis of inflammatory arthritis, osteoarthritis, or other rheumatic disease. Participants were asked about their employment experiences, formal and informal workplace resource needs, and availability and use of workplace resources. Differences based on chronological, functional, psychosocial, organizational, and lifespan dimensions of age were examined. A modified grounded theory approach was used to inductively analyze the data.

Results

Young, middle‐aged, and older adult participants required similar workplace resources. Across all participants, scheduling modifications tended to be the most needed workplace resource. In contrast, the perceived availability and use of formal workplace resources differed among participants. Young adult participants and those who were newer to their jobs reported that workplace resources were less available and utilized. Middle‐aged and older adults reported greater availability of workplace resources. Scheduling accommodations and at‐work modifications were the workplace resources that were used most by middle‐aged and older adults, respectively.

Conclusion

Similar workplace resources could meet the employment needs of individuals with arthritis across the life course. Attention should be paid to young adults and those who are new to their jobs, because they may perceive more barriers to accessing formal workplace resources and be susceptible to work disability.

     

Relationship Between Fish Consumption and Disease Activity in Rheumatoid Arthritis

Objective

To assess whether more frequent fish consumption is associated with lower rheumatoid arthritis (RA) disease activity scores among participants in an RA cohort.

Methods

We conducted a cross‐sectional analysis using baseline data from participants in the Evaluation of Subclinical Cardiovascular Disease and Predictors of Events in Rheumatoid Arthritis cohort study. Frequency of fish consumption was assessed by a baseline food frequency questionnaire assessing usual diet in the past year. Multivariable, total energy–adjusted linear regression models provided effect estimates and 95% confidence intervals (95% CIs) for frequency of fish consumption (i.e., never to <1 time/month, 1 time/month to <1 time/week, 1 time/week, and ≥2 times/week) on baseline Disease Activity Score in 28 joints (DAS28) using the C‐reactive protein (CRP) level. We also estimated the difference in DAS28‐CRP associated with increasing fish consumption by 1 serving per week.

Results

Among 176 participants, the median DAS28‐CRP score was 3.5 (interquartile range 2.9–4.3). In an adjusted linear regression model, subjects consuming fish ≥2 times/week had a significantly lower DAS28‐CRP compared with subjects who ate fish never to <1 time/month (difference ?0.49 [95% CI ?0.97, ?0.02]). For each additional serving of fish per week, DAS28‐CRP was significantly reduced by 0.18 (95% CI ?0.35, ?0.004).

Conclusion

Our findings suggest that higher intake of fish may be associated with lower disease activity in RA patients.

     

Efficacy of a Work Disability Prevention Program for People with Rheumatic and Musculoskeletal Conditions: A Single‐Blind Parallel‐Arm Randomized Controlled Trial

Objective

Work disability rates are high among people with rheumatic and musculoskeletal conditions. Effective disability preventive programs are needed. We examined the efficacy of a modified vocational rehabilitation approach delivered by trained occupational therapists and physical therapists on work limitation and work loss over 2 years among people with rheumatic and musculoskeletal conditions.

Methods

Eligibility criteria for this single‐blind, parallel‐arm randomized trial included ages 21–65 years, 15 or more hours/week employment, a self‐reported doctor‐diagnosed rheumatic or musculoskeletal condition, and concern about staying employed. The intervention consisted of a 1.5‐hour meeting, an action plan, written materials on employment supports, and telephone calls at 3 weeks and 3 months. Control group participants received the written materials. The primary outcome was the Work Limitations Questionnaire (WLQ) output job demand subscale. The secondary outcome was work loss. Intent‐to‐treat analyses were performed.

Results

Between October 2011 and January 2014, 652 individuals were assessed for eligibility. A total of 287 participants were randomized: 143 intervention and 144 control participants. In total, 264 participants (92%) completed 2‐year data collection. There was no difference in the mean ± SD WLQ change scores from baseline to 2‐year followup (?8.6 ± 1.9 intervention versus ?8.3 ± 2.2 control; P = 0.93). Of the 36 participants who experienced permanent work loss at 2 years, 11 (8%) were intervention participants and 25 (18%) control participants (P = 0.03).

Conclusion

The intervention did not have an effect on work limitations but reduced work loss. The intervention can be delivered by trained rehabilitation therapists.

     

Development and Pilot Testing of Multimedia Patient Education Tools for Patients With Knee Osteoarthritis,Osteoporosis, and Rheumatoid Arthritis

Objective

We developed and tested multimedia patient education tools (video tools) for patients with knee osteoarthritis (OA), osteoporosis (OP), and rheumatoid arthritis (RA).

Methods

We followed an “edutainment” model, incorporating educational patient story lines. The goals were designed to make the programs both didactic and entertaining, with navigation and graphic user interfaces as simple as possible. We created both English and Spanish language versions. Once the video tool was finalized, 60 patients, 20 per disease, were shown the tool and interviewed. Disease knowledge was our primary outcome, and decision conflict, disease management, and acceptability were secondary outcomes.

Results

We observed statistically significant differences in pre‐ to postintervention knowledge questionnaire scores (before and after viewing the video tool) (OA: P = 0.03, OP: P = 0.01, and RA: P < 0.0001). Most participants felt they gained “clarity” on disease duration, symptoms, and the time medication takes to start acting; were “encouraged to see their doctor regularly”; and were more aware about taking their medications. In terms of acceptability, most patients in all disease groups found the length and amount of information presented in the video tools to be “just right,” and the presentation to be “balanced.” In terms of comprehension, all participants provided a favorable evaluation of the video tool; all found the video easy to use, the vocabulary easy to understand, and the materials to be well organized.

Conclusion

Multimedia tools that incorporate videos may help patients better understand and manage their disease. Patient involvement in the development process is essential to ensure relevant content and usability.

     

Delays to Care in Pediatric Lupus Patients: Data From the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry

Objective

Prompt treatment for lupus is important to prevent morbidity. A potential barrier to early treatment of pediatric lupus is delayed presentation to a pediatric rheumatologist. To better understand factors contributing to delayed presentation among pediatric lupus patients, we examined differences in demographic and clinical characteristics of lupus patients within the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry with regard to time between symptom onset and presentation to a pediatric rheumatologist.

Methods

We analyzed data from 598 CARRA Legacy Registry participants for differences between those who presented early (within <1 month of symptom onset), between 1–3 months (typical presentation), with moderate delays (3–12 months), and with severe delays (≥1 year). Factors associated with early presentation, moderate delay, and severe delay were determined by multinomial logistic regression.

Results

Forty‐four percent of patients presented early, while 23% had moderate delays and 9% had severe delays. Family history of lupus, absence of discoid rash, and location in a state with a higher density of pediatric rheumatologists were associated with earlier presentation. Younger age, low household income (<$25,000 per year), and a family history of lupus were associated with severe delay.

Conclusion

Delays to care ≥1 year exist in a notable minority of pediatric lupus patients from the CARRA Legacy Registry. In this large and diverse sample of patients, access to care and family resources played an important role in predicting time to presentation to a pediatric rheumatologist.

     

Additional Value of Different Radiographic Views on the Identification of Early Radiographic Hip and Knee Osteoarthritis and Its Progression: A Cohort Study

Objective

To investigate the prevalence and progression of early radiographic osteoarthritis (OA ) of the hip and knee on different radiographic views, to determine whether different radiographic views have additional value in detecting early hip and knee radiographic OA cases or progression.

Methods

In the Cohort Hip and Cohort Knee (CHECK ) study (n = 1,002), 5 different radiographs were obtained: an anteroposterior and faux profile view of the hips, and posteroanterior, mediolateral, and skyline views of the knees. The prevalence of radiographic OA was estimated based on each view separately and in combinations. We determined whether different radiographic views have additional value in detecting and determining the progression of radiographic OA cases, compared to standard projections.

Results

In the hip, we found 22.9% more cases when we combined both views. In the knee, we detected 79.7% more radiographic OA cases when we combined information from all 3 different radiographic views than when using only the posteroanterior view. Progression was seen in 33.1% more cases when using 2 hip radiographs, and in 65.1% more cases when using 3 knee radiographs.

Conclusion

The use of different radiographic views increased the number of participants classified as having radiographic OA in an early OA cohort, both at baseline and at followup. The progression of early radiographic OA is demonstrated more frequently when multiple different radiographic views are used.

     

Evaluation of a Methodologic Approach to Define an Inception Cohort of Rheumatoid Arthritis Patients Using Administrative Data

Objective

Identifying incident rheumatoid arthritis (RA) is desirable in order to create inception cohorts. We evaluated an approach to identify incident RA in health plan claims data.

Methods

Both Medicare and commercial claims data were linked to Corrona, a US RA registry. We evaluated the accuracy of year of RA onset in the registry (gold standard) versus different claims algorithms, varying International Classification of Diseases, Ninth Revision codes for RA/arthritis, duration of health plan enrollment preceding diagnosis (minimum of 1 versus 2 years), and use of RA medications. Results were reported as positive predictive values (PPVs) of the claims‐based algorithm for incident RA.

Results

Depending on the algorithm tested and whether patients were enrolled in Medicare or the commercial health plan, the PPVs for incident RA ranged from 68–81%. A 2‐year clean period free of all RA‐related diagnoses and medications was somewhat more optimal although, by comparison, a 1‐year clean period yielded similar PPVs and retained approximately 90% more RA patients for analysis.

Conclusion

Claims‐based algorithms can accurately identify incident RA.

     

Fear of Movement and Associated Factors Among Adults With Symptomatic Knee Osteoarthritis

Objective

To examine the frequency of and factors associated with fear of movement (FOM ) among patients with symptomatic knee osteoarthritis (KOA ), using the new Brief Fear of Movement (BFOM ) measure.

Methods

Participants (n = 350) enrolled in a clinical trial completed the BFOM scale prior to randomization. The relationships of BFOM with the following characteristics were examined: age, sex, race, education, pain and activities of daily living (ADL ) subscales of the Knee Injury and Osteoarthritis Outcome Score (KOOS ), knee symptom duration, depressive symptoms (8‐item Patient Health Questionnaire [PHQ ‐8]), history of falls and knee injury, family history of knee problems, self‐efficacy for exercise (SEE ), and unilateral balance test. A proportional odds logistic regression model examined multivariable associations of participant characteristics with a 3‐level BFOM variable (agreement with 0, 1–2, or ≥3 items).

Results

The majority of participants (77%) agreed with at least 1 item on the BFOM scale, and 36% endorsed 3+ items, suggesting a high degree of FOM . In the multivariable model, the following remained significant after backward selection: age (odds ratio [OR ] 0.79 per 10‐point increase, 95% confidence interval [95% CI ] 0.66–0.95), KOOS ADL (OR 0.86 per 10‐point increase, 95% CI 0.76–0.97), PHQ ‐8 (OR 1.15, 95% CI 1.08–1.22), and SEE (OR 0.87 per 10‐point increase, 95% CI 0.78–0.96).

Conclusion

FOM was common among patients with symptomatic KOA , and this could negatively impact physical activity. Psychological variables were significantly associated with FOM , suggesting behavioral and psychological interventions may decrease FOM and improve outcomes among individuals with symptomatic KOA .

     

Geriatric Assessment of Physical and Cognitive Functioning in a Diverse Cohort of Systemic Lupus Erythematosus Patients: A Pilot Study

Objective

To use multidomain functional assessment, which is commonly performed in geriatric patients but is novel in patients with systemic lupus erythematosus (SLE), to better understand functional impairment in patients with SLE.

Methods

We recruited 60 adult participants (aged 20–39 years [26.7%], 40–59 years [50.0%], and ≥60 years [23.3%]; 80.0% African American and 90.0% female) from an existing cohort of SLE patients. During in‐person visits (from October 2016 to April 2017), we evaluated physical performance (range 0–4, with higher scores indicating better performance), cognitive performance (5 fluid cognition domains; adjusted T scores), and self‐reported measures including physical functioning (T scores), activities of daily living (ADLs), falls, and life‐space mobility.

Results

In the SLE patients, the mean balance score (3.7) and gait speed score (3.4) were high, while the mean lower body strength score was low (1.8). Cognitive performance was average (score of 5.0) for episodic (47.7) and working (48.6) memory and low average for cognitive flexibility (43.7), processing speed (42.6), and attention/inhibitory control (38.8 [>1 SD below average]) when compared with healthy individuals of the same age, sex, race, ethnicity, and education level. Most participants reported the ability to independently perform basic ADLs, but many reported the inability to independently perform instrumental ADLs. Nearly half (45.0%) of participants reported falling in the prior year. Only 40.0% reported unlimited ability to travel without the help of another person. Scores generally did not differ substantially according to age.

Conclusion

Our results suggest a high prevalence of impairment across multiple domains of function in SLE patients of all ages, similar to or exceeding the prevalence observed in much older geriatric populations. Further research into the added value of geriatric assessment in routine care for SLE is warranted.

     

Natural History and Predictors of Progression to Sjögren's Syndrome Among Participants of the Sjögren's International Collaborative Clinical Alliance Registry

Objective

To explore changes in the phenotypic features of Sjögren's syndrome (SS), and in SS status among participants in the Sjögren's International Collaborative Clinical Alliance (SICCA) registry over a 2–3‐year interval.

Methods

All participants in the SICCA registry who were found to have any objective measures of salivary hypofunction, dry eye, focal lymphocytic sialadenitis in minor salivary gland biopsy, or anti‐SSA/SSB antibodies were recalled over a window of 2 to 3 years after their baseline examinations to repeat all clinical examinations and specimen collections to determine whether there was any change in phenotypic features and in SS status.

Results

As of September 15, 2013, a total of 3,514 participants had enrolled in SICCA, and among 3,310 eligible, 771 presented for a followup visit. Among participants found to have SS using the 2012 American College of Rheumatology (ACR) classification criteria, 93% again met the criteria after 2 to 3 years, and this proportion was 89% when using the 2016 ACR/European League Against Rheumatism (EULAR) criteria. Among those who did not meet ACR or ACR/EULAR criteria at baseline, 9% and 8%, respectively, had progressed and met them at followup. Those with hypergammaglobulinemia and hypocomplementemia at study entry were, respectively, 4 and 6 times more likely to progress to SS by ACR criteria than those without these characteristics (95% confidence interval 1.5–10.1 and 1.8–20.4, respectively).

Conclusion

While there was stability over a 2–3‐year period of both individual phenotypic features of SS and of SS status, hypergammaglobulinemia and hypocomplementemia at study entry were predictive of progression to SS.

     

Pain and Mortality in Older Adults: The Influence of Pain Phenotype

Objective

Moderate to severe chronic pain affects 1 in 5 adults. Pain may increase the risk of mortality, but the relationship is unclear. This study investigated whether mortality risk was influenced by pain phenotype, characterized by pain extent or pain impact on daily life.

Methods

The study population was drawn from 2 large population cohorts of adults ages ≥50 years, the English Longitudinal Study of Ageing (n = 6,324) and the North Staffordshire Osteoarthritis Project (n = 10,985). Survival analyses (Cox's proportional hazard models) estimated the risk of mortality in participants reporting any pain and then separately according to the extent of pain (total number of pain sites, widespread pain according to the American College of Rheumatology [ACR] criteria, and widespread pain according to Manchester criteria) and pain impact on daily life (pain interference and often troubled with pain). Models were cumulatively adjusted for age, sex, education, and wealth/adequacy of income.

Results

After adjustments, the report of any pain (mortality rate ratio [MRR] 1.06 [95% confidence interval (95% CI) 0.95–1.19]) or having widespread pain (ACR 1.07 [95% CI 0.92–1.23] or Manchester 1.16 [95% CI 0.99–1.36]) was not associated with an increased risk of mortality. Participants who were often troubled with pain (MRR 1.29 [95% CI 1.12–1.49]) and those who reported quite a bit of pain interference (MRR 1.38 [95% CI 1.20–1.59]) and extreme pain interference (MRR 1.88 [1.54–2.29]) had an increased risk of all‐cause mortality.

Conclusion

Pain that interferes with daily life, rather than pain per se, was associated with an increased risk of mortality. Future studies should investigate the mechanisms through which pain increases mortality risk.

     

Does Education Level Mitigate the Effect of Poverty on Total Knee Arthroplasty Outcomes?

Objective

Total knee arthroplasty (TKA) outcomes are worse for patients from poor neighborhoods, but whether education mitigates the effect of poverty is not known. We assessed the interaction between education and poverty on 2‐year Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function.

Methods

Patient‐level variables from an institutional registry were linked to US Census Bureau data (census tract [CT] level). Statistical models including patient and CT‐level variables were constructed within multilevel frameworks. Linear mixed‐effects models with separate random intercepts for each CT were used to assess the interaction between education and poverty at the individual and community level on WOMAC scores.

Results

Of 3,970 TKA patients, 2,438 (61%) had some college or more. Having no college was associated with worse pain and function at baseline and 2 years (P = 0.0001). Living in a poor neighborhood (>20% below poverty line) was associated with worse 2‐year pain (P = 0.02) and function (P = 0.006). There was a strong interaction between individual education and community poverty with WOMAC scores at 2 years. Patients without college living in poor communities had pain scores that were ~10 points worse than those with some college (83.4% versus 75.7%; P < 0.0001); in wealthy communities, college was associated with a 1‐point difference in pain. Function was similar.

Conclusion

In poor communities, those without college attain 2‐year WOMAC scores that are 10 points worse than those with some college; education has no impact on TKA outcomes in wealthy communities. How education protects those in impoverished communities warrants further study.

     

Bone Mineral Density and the Risk of Hip and Knee Osteoarthritis: The Johnston County Osteoarthritis Project

Objective

To address knowledge gaps regarding the relationship between bone mineral density (BMD) and incident hip or knee osteoarthritis (OA); specifically, lack of information regarding hip OA or symptomatic outcomes.

Methods

Using data (n = 1,474) from the Johnston County Osteoarthritis Project's first (1999–2004) and second (2005–2010) followup of participants ages ≥45 years, we examined the association between total hip BMD and both hip and knee OA. Total hip BMD was measured using dual x‐ray absorptiometry, and participants were classified into sex‐specific quartiles (low, intermediate low, intermediate high, and high). Radiographic OA (ROA) was defined as development of Kellgren/Lawrence grade ≥2. Symptomatic ROA (sROA) was defined as onset of both ROA and symptoms. Weibull regression modeling was used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs).

Results

Median followup time was 6.5 years (range 4.0–10.2 years). In multivariate models, and compared with participants with low BMD, those with intermediate high and high BMD were less likely to develop hip sROA (HR 0.52 [95% CI 0.31–0.86] and 0.56 [95% CI 0.31–0.86], respectively; P = 0.024 for trend); high BMD was not associated (HR 0.69 [95% CI 0.45–1.06]) with risk of hip ROA. Compared with participants with low BMD, those with intermediate low and intermediate high total hip BMD were more likely to develop knee sROA (HR 2.15 [95% CI 1.40–3.30] and 1.65 [95% CI 1.02–2.67], respectively; P = 0.325 for trend); similar associations were seen with knee ROA.

Conclusion

Our findings suggest that higher BMD may reduce the risk of hip sROA, while intermediate levels may increase the risk of both knee sROA and ROA.

     

Septic Arthritis in Emergency Departments in the US: A National Study of Health Care Utilization and Time Trends

Objective

To assess the health care utilization and emergency department (ED) charges for septic arthritis.

Methods

We performed a retrospective cohort study of ED visits with septic arthritis as the primary diagnosis using the US Nationwide Emergency Department Sample data from 2009–2012. We examined ED charges, hospitalization, and associated time trends. Multivariable models were adjusted for demographics (age, sex, insurance status, residence, and household income), comorbidity, and hospital characteristics to assess factors associated with ED charges and hospitalization.

Results

Septic arthritis was responsible for 16,382 ED visits in 2012 in the US, which constituted 0.01% of all ED visits. The number of ED visits was stable from 2009–2012. Total ED charges were $34.6, $30.6, and $36.9 million in 2009, 2010, and 2012, respectively, and mean ED charges were $2,149, $1,866, and $2,257, respectively. The majority of the patients with an ED visit for septic arthritis were hospitalized: 82%, 83%, and 84% in 2009, 2010, and 2012, respectively. Metropolitan residence and western US location were associated with higher ED charges, and the highest income quartile, renal failure, or osteoarthritis were associated with lower ED charges. Female sex, metropolitan residence, metropolitan teaching hospital status, and medical comorbidity (diabetes mellitus, hyperlipidemia, hypertension, chronic obstructive pulmonary disease, coronary heart disease, gout, osteoarthritis, renal failure, and heart failure) were associated with a higher risk of hospitalization.

Conclusion

Comorbidities were associated with a higher risk of hospitalization after an ED visit for septic arthritis, but not higher ED charges. No time trends in ED visit incidence, ED charges, or hospitalization rate for septic arthritis from 2009–2012 were noted.

     

Bronchiectasis in indigenous and non‐indigenous residents of Australia and New Zealand

Background and objective

Bronchiectasis not associated with cystic fibrosis is an increasingly recognized chronic lung disease. In Oceania, indigenous populations experience a disproportionately high burden of disease. We aimed to describe the natural history of bronchiectasis and identify risk factors associated with premature mortality within a cohort of Aboriginal Australians, New Zealand Māori and Pacific Islanders, and non‐indigenous Australians and New Zealanders.

Methods

This was a retrospective cohort study of bronchiectasis patients aged >15 years at three hospitals: Alice Springs Hospital and Monash Medical Centre in Australia, and Middlemore Hospital in New Zealand. Data included demographics, ethnicity, sputum microbiology, radiology, spirometry, hospitalization and survival over 5 years of follow‐up.

Results

Aboriginal Australians were significantly younger and died at a significantly younger age than other groups. Age‐ and sex‐adjusted all‐cause mortality was higher for Aboriginal Australians (hazard ratio (HR): 3.9), and respiratory‐related mortality was higher for both Aboriginal Australians (HR: 4.3) and Māori and Pacific Islander people (HR: 1.7). Hospitalization was common: Aboriginal Australians had 2.9 admissions/person‐year and 16.9 days in hospital/person‐year. Despite Aboriginal Australians having poorer prognosis, calculation of the FACED score suggested milder disease in this group. Sputum microbiology varied with Aspergillus fumigatus more often isolated from non‐indigenous patients. Airflow obstruction was common (66.9%) but not invariable.

Conclusions

Bronchiectasis is not one disease. It has a significant impact on healthcare utilization and survival. Differences between populations are likely to relate to differing aetiologies and understanding the drivers of bronchiectasis in disadvantaged populations will be key.