Joel M. Hirsh

Five consecutive cases of a cutaneous vasculopathy in users of levamisole-adulterated cocaine.

Five patients with an antineutrophil cytoplasmic antibody (ANCA)-associated cutaneous vasculopathy secondary to levamisole-adulterated cocaine were prospectively followed up at a single hospital. All patients presented with retiform purpura, with ear involvement being the most characteristic finding. Cocaine metabolites were present on urine toxicology screening, with 2 of 4 of those tested also being positive for levamisole. High-titer polyspecific ANCA and positive antiphospholipid antibody tests were defining laboratory features. Thrombosis and/or leukocytoclastic vasculitis were seen on skin biopsy. Improvement of skin lesions and laboratory findings occurred with cessation of cocaine; however, arthralgias and other complications developed. Levamisole-adulterated cocaine is a cause of a cutaneous vasculopathy associated with characteristic laboratory and clinical features that allow it to be distinguished from classic ANCA-associated small-vessel vasculitides. The chronic sequelae of this syndrome and the potential role for immunosuppression are yet to be completely defined.

Health literacy predicts the discrepancy between patient and provider global assessments of rheumatoid arthritis activity at a public urban rheumatology clinic.

Objective. Numerous studies report that significant discordance exists between patient and provider [physician] measures of rheumatoid arthritis (RA). We examined whether health literacy explains this discordance. Methods. We recruited English-speaking adult patients with RA for this cross-sectional study. Subjects completed 2 versions of patient global assessments of disease activity (PTGA), using standard terminology from the Multi-Dimensional Health Assessment Questionnaire (MDHAQ) and the 28-joint count Disease Activity Score 28 (DAS28). The provider global assessment (MDGA) was also obtained. The discrepancy between PTGA and MDGA was calculated as the absolute difference between these assessments. We used validated instruments [Short Test of Functional Health Literacy in Adults (S-TOFHLA) and Rapid Estimate of Adult Literacy in Medicine (REALM)] and linear regression to determine whether health literacy predicts disease measure discrepancy. Results. The study included 110 subjects. Limited health literacy was a common finding by both the REALM and S-TOFHLA. PTGA and MDGA showed fair to good correlation (r = 0.66–0.68), although both versions of the PTGA were significantly higher than MDGA by the t-test (p < 0.001). The S-TOFHLA and REALM both were associated with the absolute difference between the MDGA and PTGA by linear regression, and results remained statistically significant in multivariate analysis. Conclusion. Health literacy was independently associated with the extent of discrepancy between PTGA and MDGA in English-speaking patients with RA at an urban clinic. This finding should influence our interpretation of disease measures.

Strong Association of Health Literacy With Functional Status Among Rheumatoid Arthritis Patients: A Cross-Sectional Study

Studies linking health literacy to outcomes in rheumatoid arthritis (RA) have been underpowered and have not adequately accounted for confounders. We examined the association of health literacy with functional status in 6,052 subjects participating in a prospective observational study, controlling for numerous important covariates.

Limited health literacy is a common finding in a public health hospital's rheumatology clinic and is predictive of disease severity.

Background:Health literacy (HL) is associated with outcomes in many conditions, but little is known about its impact on arthritic diseases. Objectives:We sought to determine whether HL is related to disease activity and severity in patients with rheumatoid arthritis (RA). Methods:English-speaking adult RA patients were recruited for this cross-sectional study. Background information was ascertained by medical record review; Disease Activity Score 28 (DAS-28) scores were determined by providers; subjects completed the Multidimensional Health Assessment Questionnaire (MDHAQ), demographic questionnaires, and validated HL instruments, including the Short Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and the single-item literacy screener. We used linear regression to assess whether HL was associated with MDHAQ and DAS-28 scores. Results:One hundred ten subjects participated in the study. Limited HL was a common finding, especially among ethnic minorities. The single-item literacy screener results were predictive of lower MDHAQ scores by univariate regression analysis. Similar trends were observed for the Short Test of Functional Health Literacy in Adults and Rapid Estimate of Adult Literacy in Medicine. The relationship between the single-item literacy screener and MDHAQ remained statistically significant in multivariate analysis that controlled for the impact of demographic features and RA disease characteristics. Health literacy scores were not associated with DAS-28 scores. Conclusions:Health literacy was independently associated with functional impairment in English-speaking RA patients at an urban safety-net clinic. This new finding suggests that RA functional status might be improved by strategies that target limited HLs causal pathways.

Application and feasibility of systemic lupus erythematosus reproductive health care quality indicators at a public urban rheumatology clinic

Objectives Quality indicators (QIs) are evidence-based processes of care designed to represent the current standard of care. Reproductive health QIs for the care of patients with systemic lupus erythematosus (SLE) have recently been developed, and examine areas such as pregnancy screening for autoantibodies, treatment of pregnancy-associated antiphospholipid syndrome, and contraceptive counseling. This study was designed to investigate our performance on these QIs and to explore potential gaps in care and demographic predictors of adherence to the QIs in a safety-net hospital. Methods We performed a record review of patients with a diagnosis of SLE at Denver Health Medical Center (DH) through an electronic query of existing medical records and via chart review. Data were limited to female patients between the ages of 18 and 50 who were seen between July 2006 and August 2011. Results A total of 137 female patients between the ages of 18 and 50 were identified by ICD-9 code and confirmed by chart review to have SLE. Of these, 122 patients met the updated 1997 American College of Rheumatology SLE criteria and had intact reproductive systems. Only 15 pregnancies were documented during this five-year period, and adherence to autoantibody screening was 100 percent. We did not have any patients who were pregnant and met criteria for pregnancy-associated antiphospholipid syndrome. Sixty-five patients (53%) received potentially teratogenic medications, and 30 (46%) had documented discussions about these medications’ potential risk upon their initiation. Predictors of whether patients received appropriate counseling included younger age (OR 0.92, CI 0.87–0.98) and those who did not describe English as their primary language (OR 0.24, CI 0.07–0.87) in the multivariate analysis. Conclusions We were able to detect an important gap in care regarding teratogenic medication education to SLE patients of childbearing potential in our public health academic clinic, as only one in two eligible patients had documented appropriate counseling at the initiation of a teratogenic medication.

A concise evaluation and management curriculum for physicians in training improved billing at an outpatient academic rheumatology clinic.

Purpose:To study whether providing house staff with a brief lecture and handout about proper documentation could improve billing at an academic rheumatology clinic. Method:The authors created an educational sheet about documentation and billing after a review of the common documentation omissions responsible for down coding (Appendix, Supplemental Digital Content 1, available at: http://links.lww.com/RHU/A8). Beginning in November of 2006, the house staff were provided with this sheet and a brief lecture regarding how outpatient evaluation and management levels of service are coded. The results of clinic billing from January 1, 2006 to October 31, 2006 and November 1, 2006 to August 31, 2007 were obtained from the physician billing office. The authors compared the average level of service, by appointment type, in the prepost comparison periods using the student t test. Results:There was a significant improvement in the level of service billed for new visits (P < 0.001), consults (P < 0.001), and return visits (P < 0.001) after November 1, 2006. The percentage of patients evaluated for the first time who were billed as consults improved from 15% to 78% (P < 0.001 by &khgr;2). These changes resulted in

Health literacy predicts discrepancies between traditional written patient assessments and verbally administered assessments in rheumatoid arthritis.

34,342 of additional billing during the postintervention period. Discussion:A simple strategy for educating the house staff about proper documentation of the history, physical examination, and clinical decision making resulted in a significant improvement in an academic rheumatology divisions outpatient billing.

Limited health literacy predicts patient confusion about patient global assessments of disease activity and rheumatoid arthritis model disease states

Objective. Patient assessments of disease activity (PtGA) and general health (GH) measured by visual analog scale (VAS) are widely used in rheumatoid arthritis (RA) clinical practice and research. These require comprehension of the question’s wording and translation of disease activity onto a written VAS, which is problematic for patients with limited health literacy (HL) or difficulty completing forms. This study’s objective was to validate verbally administered versions of patient assessments and identify factors that might explain discrepancies between verbal and written measures. Methods. We enrolled patients with RA at the Denver Health rheumatology clinic (n = 300). Subjects were randomized to complete the traditional written PtGA and GH and one of the verbal assessments. Subjects provided a verbal numeric response after reading the question, having the question read to them in person, or hearing the question over the phone. Spearman and Lin correlations comparing written and verbal assessments were determined. Multivariate logistic regression was performed to explain any discrepancies. Results. The instruments administered verbally in-person showed good, but not excellent, correlation with traditional written VAS forms (Spearman coefficients 0.59 to 0.70; p < 0.001 for all correlations). Twenty-three percent of subjects were unable to complete 1 of the written VAS assessments without assistance. HL predicted missing written data and discrepancies between verbal and written assessments (p < 0.05 for all correlations). Conclusion. Providers should use verbal versions of PtGA and GH with caution while caring for patients unable to complete traditional written version. Limited HL is widely prevalent and a barrier to obtaining patient-oriented data.

Applying Choosing Wisely: Antinuclear Antibody (ANA) and Sub- Serology Testing in a Safety Net Hospital System

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1002/acr.23692 This article is protected by copyright. All rights reserved. DR. PATRICK WOOD (Orcid ID : 0000-0002-6386-4805)Patient global assessment visual analog scales (PGA‐VAS) are widely used in rheumatoid arthritis (RA) practice and research, and low PGA‐VAS scores are required for remission. Vulnerable patients with RA may have difficulty completing the PGA‐VAS. There is limited information about both patients’ perceptions of PGA‐VAS and how patients score VAS model disease states. The objective of this study was to understand the perspectives of vulnerable patients regarding PGA‐VAS and model disease states.

The Challenge and Opportunity of Capturing Patient Reported Measures of Rheumatoid Arthritis Disease Activity in Vulnerable Populations with Limited Health Literacy and Limited English Proficiency

Objective: In 2013, the American College of Rheumatology (ACR) participated in the Choosing Wisely campaign and devised a recommendation to avoid testing antinuclear antibody (ANA) subserologies without a positive ANA and clinical suspicion of disease. The goals of our study were to describe ANA and subserology ordering practices and predictors of ordering concurrent ANA and subserologies in a safety-net hospital. Methods: We identified ANA and subserologies (dsDNA, Sm, RNP, SSA, SSB, Scl-70 and centromere) completed at Denver Health between 1/1/2005 and 12/31/2011. Variables included demographics, primary insurance, service, and setting from which the test was ordered. We performed multivariable logistic regression to determine predictors of concurrent ordering of ANA and subserologies. Results: During seven years, 3221 ANA were performed in 2771 individuals and 211 (6.6%) were performed concurrently with at least one subserology. The most common concurrent subserologies were dsDNA (21.8%), SSA (20.8%), and SSB (19.7%). In the multivariable logistic analysis, significant predictors of concurrent ANA and subserologies were the labs being ordered from subspecialty care (OR 8.12, 95% CI 5.27-12.50, p-value <0.0001) or from urgent/inpatient care (OR 3.86, 95% CI 1.78-8.38, p-value 0.001). A significant predictor of decreased odds was male gender (OR 0.32, 95% CI 0.21-0.49, p-value <0.0001). Five individuals (2.2% of the negative ANA with subserologies ordered) had a negative ANA but positive subserologies. Conclusion: Of 3221 ANA, 6.6% were performed concurrently with subserologies, and subspecialists were more likely to order concurrent tests. A negative ANA predicted negative subserologies with rare exceptions, which validates the ACR’s recommendations.