Lisa Anne Davis

Importance: Burnout is a work-related syndrome of depersonalization (DP), emotional exhaustion (EE), and low personal achievement (PA) that is prevalent among internal medicine resident trainees. Prior interventions have had modest effects on resident burnout. The association of a new 4 + 4 block schedule (4 inpatient weeks plus 4 outpatient weeks) with resident burnout has not previously been evaluated.Objective: To evaluate the association of a 4 + 4 block schedule, compared with a 4 + 1 schedule, with burnout, wellness, and self-reported professional engagement and clinical preparedness among resident physicians.Design, Setting, and Participants: This nonrandomized preintervention and postintervention survey study was conducted in a single academic-based internal medicine residency program from June 2019 to June 2021. The study included residents in the categorical, hospitalist, and primary care tracks in postgraduate years 1 and 2 (PGY1 and PGY2). Data analysis was conducted from October to December 2022.Intervention: In the 4 + 4 structure, resident schedules alternated between 4-week inpatient call-based rotations and 4-week ambulatory non–call-based rotations.Main Outcomes and Measures: The primary outcome was burnout, assessed using the Maslach Burnout Inventory subcategories of EE (range, 0-54), DP (range, 0-30), and PA (range, 0-48), adjusted for sex and PGY. Secondary outcomes included In-Training Examination (ITE) scores and a questionnaire on professional, educational, and health outcomes. Multivariable logistic regression was used to assess the primary outcome, 1-way analysis of variance was used to compare ITE percentiles, and a Bonferroni-adjusted Kruskal Wallis test was used for the remaining secondary outcomes. The findings were reexamined with several sensitivity analyses, and Cohen’s D was used to estimate standardized mean differences (SMDs).Results: Of the 313 eligible residents, 216 completed the surveys. A total of 107 respondents (49.5%) were women and 109 (50.5%) were men; 119 (55.1%) were PGY1 residents. The survey response rates were 78.0% (85 of 109) in the preintervention cohort and 60.6% (63 of 104) and 68.0% (68 of 100) in the 2 postintervention cohorts. The PGY1 residents had higher response rates than the PGY2 residents (119 of 152 [78.2%] vs 97 of 161 [60.2%]; P < .001). Adjusted EE scores (mean difference [MD], −6.78 [95% CI, −9.24 to −4.32]) and adjusted DP scores (MD, −3.81 [95% CI, −5.29 to −2.34]) were lower in the combined postintervention cohort. The change in PA scores was not statistically significant (MD, 1.4 [95% CI, −0.49 to 3.29]). Of the 15 items exploring professional, educational, and health outcomes, a large positive association was observed for 11 items (SMDs >1.0). No statistically significant change in ITE percentile ranks was noted.Conclusions and Relevance: In this survey study of internal medicine resident physicians, a positive association was observed between a 4 + 4 block training schedule and internal medicine resident burnout scores and improved self-reported professional, educational, and health outcomes. These results suggest that specific 4 + 4 block combinations may better improve resident burnout than a 4 + 1 combination used previously.

Objective: Rheumatoid arthritis (RA) is associated with increased atherosclerotic cardiovascular disease (ASCVD). General population cohorts have shown African American individuals to have greater and Hispanic Americans to have lower cardiovascular disease prevalence when compared with non‐Hispanic white individuals; however, the reasons for these findings are not clear. This systematic review seeks to describe the incidence and prevalence of ASCVD stratified by race/ethnicity within the US RA population.Methods: MEDLINE, Embase, and Cochrane databases were searched for studies that reported incidence or prevalence of ASCVD (including, but not limited to, fatal and nonfatal stroke, myocardial infarction, and cardiovascular death) in those with RA. Abstracts and full texts were screened separately for inclusion by two reviewers, with a third reviewer to resolve discrepancies.Results: We screened 2625 abstracts and fully reviewed 138 manuscripts. Twenty‐one were included that cited at a minimum the percentage of non‐Hispanic whites in their population. No publication meeting entry criteria initially stratified ASCVD by race/ethnicity. The average prevalent ASCVD in RA is 46.9% (95% CI: 46.8–47) (range of prevalent ASCVD: 30%‐47%). The average incident ASCVD is 8.2% (95% CI: 8.14–8.25) (range of incident ASCVD 1%–46%).Conclusion: In this systematic review, we found a paucity of data on racially/ethnically diverse RA patients and ASCVD outcomes. Future studies should report the prevalence of ASCVD in various races/ethnicities with RA in the United States. These data would help inform clinicians on how best to manage cardiovascular disease risk in RA.

Objective: Our objective was to determine the impact of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, on medication adherence, patient satisfaction, and feasibility in all patients; its effect on the clinical disease activity index (CDAI) was studied in a rheumatoid arthritis (RA) subpopulation.Methods: Data collected during a 6‐month prospective quality assurance intervention was compared with data from a prior 6‐month period. Interventions included 1) encouraging questions, 2) teach‐back communication, and 3) brown‐bag medication review. Analysis was performed using linear regression or generalized estimating equation (GEE) regression.Results: During the intervention period, 46 physicians completed 1737 patient visits. Questions were encouraged, and teach‐back communication was performed in more than 90% of visits. Brown‐bag medication reviews were performed in 47% of visits overall and 69% of visits in a subgroup that received additional reminder calls. Visit duration and patient satisfaction were not significantly increased. Adherence for rheumatology‐related medications that were prescribed both before and during the intervention increased by 22% (P ≤ 0.001; by GEE). Teach‐back communication predicted a statistically significant improvement in medication adherence in this subpopulation (by linear regression). The mean CDAI did not improve; however, African American race and Hispanic ethnicity were associated with a decreased CDAI (by GEE).Conclusion: Implementation of the Health Literacy Universal Precautions Toolkit, adapted for rheumatology, improved medication adherence in our safety‐net clinic, with particularly strong effects seen with teach‐back communication. In certain populations, use of the toolkit may also improve RA disease activity. This is the first study to document improved medication adherence with this intervention in a real‐world setting.

Type I diabetes (T1D) is one of the most common childhood diseases and Type 2 diabetes (T2D) is increasing at alarming rates. Given that children spend a great percentage of their time in school, this setting is a critical environment for models of care that lead to better management of this and other health conditions. The School Nurses Managing Diabetes Care ECHO was offered to Colorado school nurses to build their capacity in providing evidence-based management of T1D. The purpose of this effort was to (1) determine whether or not the model could be used as a tool of collaboration and dissemination for school nurses across Colorado and (2) assess the effectiveness of the “School Nurses Managing Diabetes Care” ECHO learning series. Post-series survey results demonstrated a 25% increase in self-efficacy ratings, moving learners from “average among my peers” toward “competent.” Additionally, all respondents planned to make one or more practice changes to improve care for students with T1D. Expanding the use of the ECHO model to implement intensive management of children and youth with T1D is critically important as rates of this and other chronic conditions continue to increase.

Objective: 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.Methods: We enrolled patients with RA at Denver Health (n = 300). Subjects completed the PGA‐VAS in the Disease Activity Score in 28 joints and the Multidimensional Health Assessment Questionnaire and completed a questionnaire regarding these PGA‐VAS. Subjects also scored remission, mild, moderate, and severe model disease states by VAS. We performed analyses by linear and logistic regression and by using summary statistics. Outcomes included whether subjects found the PGA‐VAS confusing, whether subjects’ responses to the model disease states followed a natural progression (remission <mild <moderate <severe), and whether responses to the remission model would meet Boolean and Simplified Disease Activity Index–based remission criteria.Results: Approximately 40% of subjects found the PGA‐VAS confusing; lower health literacy and depressive symptoms were associated with finding them confusing. Less than 25% of subjects ranked the model disease states with natural progression and ranked the remission model at the threshold for remission; higher health literacy and income were associated with accomplishing these objectives.Conclusion: Vulnerable patients perceive difficulty with PGA‐VAS and do not reliably rate a model disease state VAS. These patients are potentially at risk for disease activity misclassification because of literacy and other barriers in completing VAS.

Purpose: This study reports the effect of disease-modifying therapies for rheumatoid arthritis (RA) on systolic and diastolic blood pressure (SBP, DBP) over 6 months and incident hypertension over 3 years in a large administrative database. Methods: We used administrative Veterans Affairs databases to define unique dispensing episodes of methotrexate, leflunomide, sulfasalazine, hydroxychloroquine, tumor necrosis factor inhibitors, and prednisone among patients with RA. Changes in SBP and DBP in the 6 months before disease-modifying antirheumatic drug initiation were compared with changes observed in the 6 months after initiation. The risk of incident hypertension within 3 years (new diagnosis code for hypertension and prescription for antihypertensive) was also assessed. Multivariable models and propensity analyses assessed the impact of confounding by indication. Results: A total of 37,900 treatment courses in 21,216 unique patients contributed data. Overall, there were no changes in SBP or DBP in 6 months prior to disease-modifying antirheumatic drug initiation (all P > 0.62). In contrast, there was a decline in SBP (β = −1.08 [−1.32 to −0.85]; P < 0.0001) and DBP (β = −0.48 [−0.62 to −0.33]; P < 0.0001) over the 6 months following initiation. The greatest decline was observed among methotrexate and hydroxychloroquine users. Methotrexate users were 9% more likely to have optimal blood pressure (BP) after 6 months of treatment. Patients treated with leflunomide had increases in BP and a greater risk of incident hypertension compared with patients treated with methotrexate (hazard ratio, 1.53 [1.21–1.91]; P < 0.001). Conclusions: Blood pressure may improve with treatment of RA, particularly with methotrexate or hydroxychloroquine. Leflunomide use, in contrast, is associated with increases in BP and a greater risk of incident hypertension.

AIM To determine the scope of acute hypoglycemic effects for certain anti-rheumatic medications in a large retrospective observational study. METHODS Patients enrolled in the Veterans Affairs Rheumatoid Arthritis (VARA) registry were selected who, during follow-up, initiated treatment with tumor necrosis factor inhibitors (TNFi's, including etanercept, adalimumab, infliximab, golimumab, or certolizumab), prednisone, or conventional disease-modifying anti-rheumatic drugs (DMARDs), and for whom proximate random blood glucose (RBG) measurements were available within a window 2-wk prior to, and 6 mo following, medication initiation. Similar data were obtained for patients with proximate values available for glycosylated hemoglobin A1C values within a window 2 mo preceding, and 12 mo following, medication initiation. RBG and A1C measurements were compared before and after initiation events using paired t-tests, and multivariate regression analysis was performed including established comorbidities and demographics. RESULTS Two thousands one hundred and eleven patients contributed at least one proximate measurement surrounding the initiation of any examined medication. A significant decrease in RBG was noted surrounding 653 individual hydroxychloroquine-initiation events (-3.68 mg/dL, P = 0.04), while an increase was noted for RBG surrounding 665 prednisone-initiation events (+5.85 mg/dL, P < 0.01). A statistically significant decrease in A1C was noted for sulfasalazine initiation, as measured by 49 individual initiation events (-0.70%, P < 0.01). Multivariate regression analyses, using methotrexate as the referent, suggest sulfasalazine (beta = -0.58, P = 0.01) and hydroxychloroquine (beta = -5.78, P = 0.01) use as predictors of lower post-medication-initiation RBG and A1C values, respectively. Analysis by drug class suggested prednisone (or glucocorticoids) as predictive of higher medication-initiation event RBG among all start events as compared to DMARDs, while this analysis did not show any drug class-level effect for TNFi. A diagnosis of congestive heart failure (beta = 4.69, P = 0.03) was predictive for higher post-initiation RBG values among all medication-initiation events. CONCLUSION No statistically significant hypoglycemic effects surrounding TNFi initiation were observed in this large cohort. Sulfasalazine and hydroxychloroquine may have epidemiologically significant acute hypoglycemic effects.

Objective: To examine associations of body mass index (BMI) and weight loss with cause‐specific mortality in rheumatoid arthritis (RA).Methods: A cohort of US veterans with RA was followed until death or through 2013. BMI was categorized as underweight, normal, overweight, and obese. Weight loss was calculated as the 1) annualized rate of change over the preceding 13 months, and 2) cumulative percent. Vital status and cause of death were obtained from the National Death Index. Multivariable competing‐risks regression models were utilized to assess the time‐varying associations of BMI and weight loss with cause‐specific mortality.Results: Among 1,600 participants and 5,789 patient‐years of followup, 303 deaths occurred (95 cardiovascular, 74 cancer, and 46 respiratory). The highest weight‐loss rate and weight‐loss percent were associated with a higher risk of cardiovascular mortality (rate: subdistribution hazard ratio [sHR] 2.27 [95% confidence interval (95% CI) 1.61–3.19]; percent: sHR 2.31 [95% CI 1.06–5.01]) and cancer mortality (rate: sHR 2.36 [95% CI 1.11–5.01]; percent: sHR 1.90 [95% CI 1.00–3.62]). Overweight BMI was protective of cardiovascular mortality (sHR 0.59 [95% CI 0.38–0.91]), while underweight BMI was associated with a near 3‐fold increased risk of respiratory mortality (sHR 2.93 [95% CI 1.28–6.67]). Incorporation of time‐varying BMI and weight loss in the same models did not substantially alter individual associations for cardiovascular and cancer mortality, but an association between weight‐loss percentage and respiratory mortality was attenuated after BMI adjustment.Conclusion: Both BMI and weight loss are predictors of cause‐specific mortality in RA. Weight loss is a strong predictor of cardiovascular and cancer mortality, while underweight BMI is a stronger predictor of respiratory mortality.