Glucocorticoid use associated with nearly double the risk for infection after joint replacement surgery in patients with RA

1. Glucocorticoid use associated with nearly double the risk for infection after joint replacement surgery in patients with RA
Biologics had similar risk for adverse events across treatments
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2217
Editorial: http://annals.org/aim/article/doi/10.7326/M19-1088
URLs go live when the embargo lifts

Glucocorticoid use, especially with dosages above 10 mg/d, was associated with greater risk for adverse events among patients with rheumatoid arthritis (RA) undergoing joint replacement surgery. Risk for hospitalized infection, prosthetic joint infection, and readmission were similar across biologics. Findings from a cohort study are published in Annals of Internal Medicine.

Patients with RA frequently have orthopedic surgery, especially total hip or knee replacement. Biologic medications are increasingly used to treat RA and are associated with greater risk for serious infection, yet it is not known how these medications affect the risk of infection after surgery and whether risk varies across medications.

Researchers from the University of Pennsylvania Hospital used administrative claims data to compare infection risk across biologic therapies for primary or revision hip or knee joint replacement surgery in adults with rheumatoid arthritis. They also evaluated the risk for postoperative infection associated with glucocorticoids. They found that the rates of serious postoperative infection and 30-day readmission were similar between biologics. In contrast, glucocorticoids were associated with a dose-dependent increase in the risk for adverse outcomes, with greater risk even with modest doses. According to the researchers, these findings suggest that limiting glucocorticoid use should be a focus of perioperative management.

The authors of an accompanying editorial from the University of Toronto agree that the study provides compelling evidence of the risk for adverse post-operative outcomes with glucocorticoids but note that the study does not resolve the question of whether withholding biologic therapies in the perioperative period reduces patients' overall risk for infection complications. They suggest that more research is critical to answering that question.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Michael George, MD, please contact Frank Otto at Frank.Otto@pennmedicine.upenn.edu.

2. Hospital readmission rates vary little among primary care physicians
Policies that hold PCPs accountable for reducing readmissions may miss the mark
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2526
URLs go live when the embargo lifts

Thirty-day hospital readmission rates vary only slightly among primary care physicians, suggesting that policies holding them accountable for reducing readmissions may be ineffective. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Programs directed at decreasing payments to hospitals with excess 30-day readmission rates seem to have succeeded in reducing readmissions. With this in mind, the Centers for Medicare & Medicaid Services (CMS) implemented a policy incentivizing primary care physicians to reduce hospital readmissions. However, it is not actually known whether readmission rates vary by primary care physician.

Researchers from the Medical College of Wisconsin and University of Texas Medical Branch studied Texas Medicare claims from 2008 to 2015 to compare 30-day readmission rates for more than 4,000 primary care physicians. The researchers looked at data for a 47 month period because any evaluations based on yearly data would have only about a quarter as many cases. They also only reviewed data on physicians with at least 50 hospital admissions, which excluded 65 percent of the primary care physicians in the Texas Medicare data. They found almost no variation in the readmission rates by primary care physician. After adjusting for patient characteristics, the readmission rate at the 99th percentile and the mean rate for the 4,230 physicians studied varied by only 1.1 percentage points.

According to the researchers, these findings suggest that pay-for-performance programs to reduce readmissions on the basis of variation in readmission rates among primary care physicians may not be effective.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. The lead author, Siddhartha Singh, MD, MS, please contact Holly Botsford at hbotsford@mcw.edu.

3. Poor broadband penetration in rural counties may limit the potential of telemedicine
Abstract: http://annals.org/aim/article/doi/10.7326/M19-0283
Abstract: http://annals.org/aim/article/doi/10.7326/M19-1200
URLs go live when the embargo lifts

Broadband penetration rates are substantially lower in many rural counties where access to primary care physicians and psychiatrists is inadequate, which limits the potential of telemedicine to mitigate barriers to care. Findings from a brief research report are published in Annals of Internal Medicine.

Telemedicine has been proposed as a way to improve access to care in areas where physicians are in short supply, but it can only work if doctors and patients can access the Internet.

Researchers from the University of Pittsburgh, the University of Pennsylvania, and Johns Hopkins University used IQVIA's OneKey healthcare provider database and Google Maps to determine whether counties had adequate driving time-based access to primary care physicians and psychiatrists, and Federal Communications Commission (FCC) data to measure whether counties had sufficient broadband internet access. The researchers found that broadband penetration rates decreased as counties became more rural, and counties with inadequate access to primary care physicians and/or psychiatrists generally had poorer broadband penetration rates. For example, the broadband penetration rate in the most rural counties was 62.4 percent if primary care physician access was adequate, compared with 38.6 percent if it was inadequate. This relationship between access and broadband penetration was similar for psychiatrists. The authors suggest that telemedicine cannot address geographic barriers to care until telecommunications infrastructure is improved.

The authors of an accompanying editorial from Project ECHO, University of New Mexico, suggest that broadband penetration may not be the only issue deterring use of telemedicine in rural areas. The authors propose several recommendations for increasing adoption of telehealth in rural areas that include more efficient use of telemedicine; alignment of incentives and policy to support training of primary care clinicians; changes in policy and regulation to allow greater convenience for patients; and adaption of proven solutions to meet patient needs in areas that lack medical providers.

Notes and media contacts: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. The lead author, Coleman Drake, PhD, please contact Allison Hydzik at hydzikam@upmc.edu.

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Cases in Precision Medicine: The Role of Pharmacogenetics in Precision Prescribing
Bohan Lin, BA, and Wendy K. Chung, MD, PhD
Precision Medicine
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2357