Study Objectives To examine the outpatient opioid prescribing practices and the factors associated with opioid prescriptions in patients with Rheumatoid Arthritis (RA). Design This cross-sectional study used the 2011-2016 National Ambulatory Medical Care Survey. Descriptive weighted analyses were used to examine the trends in opioid prescribing practices for RA. Multivariable logistic regression was used to examine the factors associated with opioid prescriptions among RA visits. Subjects Adult patients with a primary diagnosis of RA based on the International Classification of Diseases Results According to the national surveys, an average of 4.45 (95% Confidence Interval [CI], 2.30-6.60) million office visits were made annually for RA. Approximately 24.28% of these visits involved opioid prescriptions. The RA visits involving opioid prescriptions increased from 1.43 million in 2011-2012 to 3.69 million in 2015-2016 (P < 0.0001). Being in the age group of 50-64 years (odds ratio [OR] = 3.40; 95% CI, 1.29-9.00), being Hispanic or Latino (OR = 2.92, 95% CI, 1.10-7.74), visiting primary physician (OR = 4.67; 95% CI, 1.86-11.75), muscle relaxants (OR = 64.32; 95% CI, 9.71-426.09), acetaminophen (OR = 93.40; 95% CI, 26.19-333.04), antidepressants (OR = 6.10; 95% CI, 2.63-14.14), and glucocorticoids (OR = 3.20; 95% CI, 1.61-6.38) were associated with an increased likelihood of receiving opioid prescriptions in RA. Conclusions One in four adult RA visits resulted in opioid prescriptions, and the opioid visits rate more than doubled during the study period. Several patient and provider factors were associated with the opioid prescribing among RA visits. Understanding these prescribing practices can help to devise strategies for safe opioid prescribing practices in RA.
INTRODUCTION: Hepatitis C virus (HCV) infection is a major cause of hepatic and extrahepatic morbidity and mortality. In spite of recommendations for HCV screening, diagnosis, linkage to care and treatment, significant gaps remain in the cascade of care for HCV. As the role of physician specialties for closing these gaps is poorly understood, this study assesses the flow of HCV patients across physician specialties in the US, over the course of the care cascade. METHODS: This retrospective real-world study used two large de-identified national laboratory datasets (2013–2016). Screened patients had a HCV antibody (AB) test and/or HCV RNA viral load test. Diagnosed patients had a positive HCV RNA viral load test, and among this group, fibrosis assessment, genotype test and treatment were evaluated. Treatment was inferred with an algorithm based on changes in viral load. The number/proportion of patients at each step in the care cascade was calculated by physician specialty. Patient flow by physician specialty over the course of care cascade was assessed using Sankey Diagrams. RESULTS: Approximately 17 million patients received HCV screening, and 913,529 were diagnosed. Over the course of the care cascade, there was an increase in the proportion of patients switching to HCV specialists (gastroenterologist, hepatologist, and infectious disease specialist). Generalists (primary care, family practice, internal medicine) ordered 37% of the AB tests, and 15% initiated treatment. HCV specialists ordered 3% of screening tests and 37% initiated treatment. Most of the fibrosis assessment (30%) and genotype tests (29%) were ordered by HCV specialists. Obstetricians/gynecologists ordered 11% of screening tests but only 0.3% initiated treatment. Among 974,277 patients who received a positive AB test, 46% did not receive a confirmatory RNA test. Among diagnosed patients, 57% did not receive fibrosis assessment, 47% did not receive genotype test and 90% did not receive treatment. CONCLUSION: Generalists account for more than one third of all HCV screening tests, however, HCV specialists play a more prominent role in patient assessment (fibrosis status, genotype testing) and treatment. Significant gaps remain in all stages of the cascade of care for HCV, and improved efforts are needed for every physician specialty to address them. Timely screening, monitoring and linkage to care by generalists coupled with early treatment by specialists could effectively reduce the hepatic and extrahepatic burden of HCV.
Background: Inhaled nitric oxide (iNO) has been studied in patients with severe acute respiratory distress syndrome (ARDS) due to COVID-19 when it may be too late to impact disease course. This article aims to describe real-world iNO use and outcomes in patients with COVID-19 with mild-to-moderate ARDS in the United States.Methods: This was a retrospective medical chart review study that included patients who were ≥18 years old, hospitalized for COVID-19, met the Berlin ARDS definition, received iNO for ≥24 hours continuously during hospitalization, and had a partial pressure of oxygen (PaO 2 )/fraction of inspired oxygen (FiO 2 ) ratio (P/F ratio) of >100 to ≤300 mmHg at iNO initiation. Outcomes included oxygenation parameters, physician-rated Clinical Global Impression-Improvement (CGI-I) scale scores, and adverse events. Response to iNO was defined as >20% improvement in P/F ratio.Results: Thirty-seven patients at six sites were included. A P/F ratio of ≤100 was the most common reason for exclusion (n=146; 83% of excluded patients). The mean P/F ratio (SD) increased from 136.7 (34.4) at baseline to 140.3 (53.2) at 48 hours and 151.8 (50.0) at 72 hours after iNO initiation. The response rate was 62% (n=23). During hospitalization, no patient experienced adverse events, including methemoglobinaemia, airway injury, or worsening pulmonary oedema associated with iNO. At discharge, 54.0% (n=20) of patients improved or remained stable according to the CGI-I. Conclusion:In patients hospitalized with COVID-19 and mildto-moderate ARDS, iNO was associated with improvement in the P/F ratio with no reported toxicity. This study provides additional evidence supporting a favourable benefit-risk profile for iNO in the treatment of mild-to-moderate ARDS in patients with COVID-19 infection.
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