Context In 2005, HEDIS introduced a quality measure to assess the receipt of disease modifying anti-rheumatic drugs (DMARDs) among patients with rheumatoid arthritis (RA). Objective To identify sociodemographic, community, and health-plan factors associated with DMARD receipt among Medicare managed care enrollees. Design, Setting, and Patients We analyzed individual-level HEDIS data for 93,143 patients ≥ 65 years old with at least 2 diagnoses of RA within a measurement year (during 2005–2008). Logistic regression models with generalized estimating equations were used to determine factors associated with DMARD receipt. We used logistic regression to adjust health plan performance for case-mix. Main Outcome Measure DMARD receipt (yes/no). Results The mean age of patients was 74 years; 75% were female, and 82% were white. Overall performance on the HEDIS RA measure was 59% in 2005, rising to 67% in 2008 (p for trend <.01). The largest difference in performance was based on age: patients ≥ 85 had a 30% (29%, 32%), p<.001) point lower rate of DMARD receipt compared to patients 65–69, even after adjusting for other factors. Males (−3%, 95% CI (−5%, −2%), p<.001), blacks (−4%, 95% CI (−6%, −2%), p<.001), patients with low personal income(−6%, 95% CI (−8%,−5%), p<.001), and those with the lowest ZIP-code-based socioeconomic status (SES) (−4%, 95% CI (−6%,−2%), p<.001) were also found to have lower percentage point rates, as were patients in the Middle (−7%, 95% CI (−13%,−2%), p<.001) and South Atlantic regions (−11%, 95% CI (−20%,−3%), p<.001, compared to the Pacific) and patients enrolled in for-profit health plans (−4%, 95% CI (−7%,−0%), p<.001). Performance varied widely by health plan, ranging from 16% to 87%. Conclusions Among Medicare managed care enrollees carrying a diagnosis of RA between 2005 and 2008, 63% received a DMARD; DMARD receipt varied based on demographic factors, SES, geographic location, and health plan.

Objective To examine disease activity versus treatment as lymphoma risk factors in systemic lupus erythematosus (SLE). Methods We performed case–cohort analyses within a multisite SLE cohort. Cancers were ascertained by regional registry linkages. Adjusted HRs for lymphoma were generated in regression models, for time-dependent exposures to immunomodulators (cyclophosphamide, azathioprine, methotrexate, mycophenolate, antimalarial drugs, glucocorticoids) demographics, calendar year, Sjogren’s syndrome, SLE duration and disease activity. We used adjusted mean SLE Disease Activity Index scores (SLEDAI-2K) over time, and drugs were treated both categorically (ever/never) and as estimated cumulative doses. Results We studied 75 patients with lymphoma (72 non-Hodgkin, three Hodgkin) and 4961 cancer-free controls. Most lymphomas were of B-cell origin. As is seen in the general population, lymphoma risk in SLE was higher in male than female patients and increased with age. Lymphomas occurred a mean of 12.4 years (median 10.9) after SLE diagnosis. Unadjusted and adjusted analyses failed to show a clear association of disease activity with lymphoma risk. There was a suggestion of greater exposure to cyclophosphamide and to higher cumulative steroids in lymphoma cases than the cancer-free controls. Conclusions In this large SLE sample, there was a suggestion of higher lymphoma risk with exposure to cyclophosphamide and high cumulative steroids. Disease activity itself was not clearly associated with lymphoma risk. Further work will focus on genetic profiles that might interact with medication exposure to influence lymphoma risk in SLE.

Objective. To systematically develop a quality indicator (QI) set for systemic lupus erythematosus (SLE).Methods. We used a validated process that combined available scientific evidence and expert consensus to develop a QI set for SLE. We extracted 20 candidate indicators from a systematic literature review of clinical practice guidelines pertaining to SLE. An advisory panel revised and augmented these candidate indicators and, through 2 rounds of voting, arrived at 25 QIs. These QIs advanced to the next phase of the project, in which we employed a modification of the RAND/UCLA Appropriateness Method. A systematic review of the literature was performed for each QI, linking the proposed process of care to potential improved health outcomes. After reviewing this scientific evidence, a second interdisciplinary expert panel convened to discuss the evidence and provide final ratings on the validity and feasibility of each QI. Results. The final expert panel rated 20 QIs as both valid and feasible. Areas covered included diagnosis, general preventive strategies (e.g., vaccinations, sun avoidance counseling, and screening for cardiovascular disease), osteoporosis prevention and treatment, drug toxicity monitoring, renal disease, and reproductive health. Conclusion. We employed a rigorous multistep approach with systematic literature reviews and 2 expert panels to develop QIs for SLE. This new set of indicators provides an opportunity to assess health care quality in patients with SLE and represents an initial step toward the important goal of improving care in this patient population. INTRODUCTIONLong-term survival of patients with systemic lupus erythematosus (SLE) has improved greatly over the last several decades, but morbidity from the disease and complications of medical therapy remain important concerns. Although many studies have explored risk factors associated with poor outcomes in SLE (1-4), few studies have investigated the quality of health care received by patients with this condition (5,6). One important barrier to such research is the lack of consensus on health care processes constituting high-quality care in SLE. We aimed to address this gap by developing a quality indicator (QI) set for SLE.Over the last decade, research focusing on quality measurement in health care has burgeoned, partly in response to the initiative launched by the Institute of Medicine in 1996 to assess and improve health care quality. The Institute of Medicine defined quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge" (7). In the US, the most commonly used tools to measure quality have taken the form of QIs, defined as "retrospectively measurable elements of practice performance for which there is evidence or consensus that can be used to assess the qual- Arthritis & Rheumatism (Arthritis Care & Research) Vol. 61, No. 3, March 15, 2009, pp 370 -377 DOI 10.1002/art.24356 © 2009, American College ...

Background: Exposure to environmental tobacco smoke (ETS), which contains potent respiratory irritants, may lead to chronic airway inflammation and obstruction. Although ETS exposure appears to cause asthma in children and adults, its role in causing COPD has received limited attention in epidemiologic studies.

Background Health outcomes in rheumatoid arthritis (RA) have improved significantly over the past two decades. However, research suggests that disparities exist by race/ethnicity and socioeconomic status, with certain vulnerable populations remaining understudied. Our objective was to assess disparities in disease activity and function by race/ethnicity and explore the impact of language and immigrant status at clinics serving diverse populations. Methods A cross-sectional study of 498 adults with confirmed RA at two rheumatology clinics, a university hospital clinic and a public county hospital clinic. Outcomes included the Disease Activity Score 28 (DAS-28), its components, and a measure of function, the Health Assessment Questionnaire (HAQ). We estimated multivariable linear regression models including interaction terms for race/ethnicity and clinic site. Results After adjusting for age, gender, education, disease duration, rheumatoid factor and medication use, clinically meaningful and statistically significant differences in DAS-28 and HAQ were seen by race/ethnicity, language, and immigrant status. Lower disease activity and better function was observed among Whites compared to non-Whites at the university hospital. This same pattern was observed for disease activity by language (English compared to non-English) and immigrant status (U.S.-born compared to immigrant) at the university clinic. No significant differences in outcomes were found at the county clinic. Conclusion The relationship between social determinants and RA disease activity varied significantly across clinic setting with pronounced variation at the university, but not at the county clinic. These disparities may be a result of events that preceded access to subspecialty care, poor adherence, or healthcare delivery system differences.