OBJECTIVE:This study investigated the association between frailty and cancer incidence and mortality in patients with rheumatoid arthritis (RA). It aimed to identify how frailty influences cancer risk and cancer-specific outcomes. METHODS:This retrospective cohort study analyzed data from the Veterans' Affairs Rheumatoid Arthritis Registry (2002-2023). Frailty status was categorized at baseline using the Veterans Affairs Frailty Index (VA-FI): robust (VA-FI <0.10), prefrail (VA-FI 0.11-0.20), and frail (VA-FI >0.20). Cancer incidence and cancer-related deaths were evaluated using competing risk models, adjusting for demographics, lifestyle factors (eg, smoking), RA characteristics (eg, seropositivity, Disease Activity Score-28), medication use, and comorbidities. We additionally studied domain-specific frailty exposures and linear frailty modeling in sensitivity analyses. RESULTS:A total of 2,723 individuals met eligibility criteria (mean age: 63.8 ± 11.2 years; 87.6% male; 15.4% Black). Age-adjusted cancer incidence rates per 1,000 person-years were 12.3 (robust), 15.5 (prefrail), and 19.9 (frail). In fully adjusted models, prefrailty (subdistribution hazard ratio [sHR] 1.37, 95% confidence interval [CI] 1.02-1.84) and frailty (sHR 1.83, 95% CI 1.23-2.71) were significantly associated with higher cancer incidence. Cancer-related mortality rates were 7.8 (robust), 10.6 (prefrail), and 9.8 (frail) per 1,000 person-years, with no significant associations for overall frailty. Domain-specific and sensitivity analyses were consistent with these findings. CONCLUSION:Frailty was independently associated with increased cancer incidence in RA, suggesting frailty may help identify patients at higher risk for malignancy.

Importance:Guidelines recommend dose reduction or discontinuation of long-term opioid therapy when harm outweighs benefit, but strategies to help patients do so are limited. Objective:To test optionally switching to buprenorphine as a strategy for improving pain and reducing opioids among patients prescribed high-dose, full agonist long-term opioid therapy. Design, Setting, and Participants:In this pragmatic, multisite, 12-month randomized clinical trial with masked outcome assessment, patients treated at Veterans Affairs primary care clinics were recruited from October 2017 to March 2021, with follow-up completed June 2022. Eligible patients had moderate to severe chronic pain despite high-dose opioid therapy (≥70 mg/d for at least 3 months). Patients were randomized to having the option to switch to buprenorphine or not having the option to switch. Interventions:The buprenorphine option was discussed with eligible patients as part of a larger trial of collaborative pain care interventions. Those who switched had structured follow-up to optimize dosing and address adverse effects. Main Outcomes and Measures:The primary outcome was Brief Pain Inventory total score at 12 months. The main secondary outcome was opioid dose in morphine milligram equivalents at 12 months. Results:Of 207 included participants, 185 (89.4%) were male, and the mean (SD) age was 60.9 (10.2) years. A total of 104 were randomized to the buprenorphine option and 103 to the no buprenorphine option. In the buprenorphine option arm, 27 participants (26.0%) switched. Over 12 months, the mean (SD) Brief Pain Inventory score improved from 6.8 (1.5) to 6.1 (1.9; adjusted mean difference [AMD], -0.59; 95% CI, -0.89 to -0.29) in the buprenorphine option arm and from 6.8 (1.6) to 6.3 (1.7; AMD, -0.50; 95% CI, -0.81 to 0.20) in the no option arm (between-group AMD, -0.09; 95% CI, -0.52 to 0.34). Over 12 months, mean (SD) opioid dosage decreased from 157 (75) mg/d to 94 (98) mg/d in the buprenorphine option arm (AMD, -61.0 mg/d; 95% CI, -74.1 to -47.9) and from 165 (88) mg/d to 107 (89) mg/d (AMD, -58.5 mg/d; 95% CI, -71.6 to -45.4) in the no option arm (between-group AMD, -2.5 mg/d; 95% CI, -21.1 to 16.0). Conclusions and Relevance:In this trial, outcomes did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage, but the proportion of participants who switched to buprenorphine was low. Trial Registration:ClinicalTrials.gov Identifier: NCT03026790.

We evaluated changes in long-term glucocorticoid (GC) use and factors associated with persistent GC use in older adults with late-onset rheumatoid arthritis (LORA). Using 20% Medicare data from 2008 to 2017, we identified adults ≥66 years with a new diagnosis of LORA, disease-modifying antirheumatic drug (DMARD) use or at least two rheumatologist visits, and at least 12 months of follow-up data. Older adults were categorized as DMARD-exposed or DMARD-unexposed based on treatment during the 12 months after LORA diagnosis (index date). For each quarter after the index date, long-term GC use was defined as having oral GC prescriptions for at least 30 days with a dose >5 mg/day prednisone equivalent. We compared long-term GC use between quarter (Q)1 and Q4 and performed stratified mixed-effects logistic regression for factors associated with persistent GC use, defined as long-term GC use in Q2 to Q4. The cohort included 15,425 individuals with two-thirds (62.5%) being DMARD-exposed. Between Q1 and Q4, the proportion of older adults on long-term GC declined from 44.1 to 24.9% (∆19.2%) among the DMARD-exposed and from 25.8 to 17.9% (∆7.9%) among the DMARD-unexposed. One year after the index date, 13.5% of the DMARD-exposed and 9.8% of the DMARD-unexposed were persistent GC users. In stratified mixed-effects logistic models, persistent GC use was associated with low-income subsidy status among the DMARD-exposed and with greater comorbidity burden among DMARD-unexposed. Long-term GC use declined more among DMARD-exposed than DMARD-unexposed patients. One in seven DMARD-exposed and one in ten DMARD-unexposed have persistent GC use which is associated with financial barriers and multimorbidity that may limit the use of steroid-sparing DMARDs.

BackgroundInterstitial pneumonia with autoimmune features (IPAF) is a subset of interstitial lung disease that manifests with features of autoimmunity while not meeting classification criteria for a defined rheumatic disease. Comorbidity burden is an important prognostic indicator in various rheumatic and interstitial lung diseases, but few studies have commented on comorbidities in this population. This study was conducted to evaluate the association of individual comorbidities, the Charlson Comorbidity Index (CCI), and the Rheumatic Disease Comorbidity Index (RDCI) with lung disease progression and transplant/mortality outcomes in patients with IPAF.MethodsIn a retrospective study, we evaluated the prevalence and severity of comorbidities in an institutional cohort of patients with IPAF. Using Cox regression, we correlated the association of individual comorbidities and comorbidity indices with time to lung disease progression (relative forced vital capacity decline of 10% or more) and with time to lung transplant/death. We compared the performance of CCI and RDCI in predicting outcomes.ResultsHistory of cerebrovascular accident (CVA) or cardiovascular disease (CVD), moderate-severe chronic kidney disease, and fracture was associated with a faster onset of lung disease progression, while a history of gastroesophageal reflux was protective. History of CVA/CVD, diabetes mellitus, and lymphoma were associated with a faster onset of lung transplant/death. Both CCI and RDCI were associated with shorter time to lung disease progression and lung transplant/death in unadjusted analyses. However, only CCI was associated with shorter time to lung transplant/death in analyses adjusted for age, sex, pulmonary function, and radiographic pattern of lung lesion.ConclusionsCCI and RDCI may be useful tools in assessing prognosis in patients with IPAF in terms of both lung disease progression and mortality. Prospective studies are needed to further evaluate the performance of CCI and RDCI and the impact of optimizing comorbid conditions that may mitigate poor outcomes among patients with IPAF.

ImportanceGuidelines recommend dose reduction or discontinuation of long-term opioid therapy when harm outweighs benefit, but strategies to help patients do so are limited.ObjectiveTo test optionally switching to buprenorphine as a strategy for improving pain and reducing opioids among patients prescribed high-dose, full agonist long-term opioid therapy.Design, Setting, and ParticipantsIn this pragmatic, multisite, 12-month randomized clinical trial with masked outcome assessment, patients treated at Veterans Affairs primary care clinics were recruited from October 2017 to March 2021, with follow-up completed June 2022. Eligible patients had moderate to severe chronic pain despite high-dose opioid therapy (≥70 mg/d for at least 3 months). Patients were randomized to having the option to switch to buprenorphine or not having the option to switch.InterventionsThe buprenorphine option was discussed with eligible patients as part of a larger trial of collaborative pain care interventions. Those who switched had structured follow-up to optimize dosing and address adverse effects.Main Outcomes and MeasuresThe primary outcome was Brief Pain Inventory total score at 12 months. The main secondary outcome was opioid dose in morphine milligram equivalents at 12 months.ResultsOf 207 included participants, 185 (89.4%) were male, and the mean (SD) age was 60.9 (10.2) years. A total of 104 were randomized to the buprenorphine option and 103 to the no buprenorphine option. In the buprenorphine option arm, 27 participants (26.0%) switched. Over 12 months, the mean (SD) Brief Pain Inventory score improved from 6.8 (1.5) to 6.1 (1.9; adjusted mean difference [AMD], −0.59; 95% CI, −0.89 to −0.29) in the buprenorphine option arm and from 6.8 (1.6) to 6.3 (1.7; AMD, −0.50; 95% CI, −0.81 to 0.20) in the no option arm (between-group AMD, −0.09; 95% CI, −0.52 to 0.34). Over 12 months, mean (SD) opioid dosage decreased from 157 (75) mg/d to 94 (98) mg/d in the buprenorphine option arm (AMD, −61.0 mg/d; 95% CI, −74.1 to −47.9) and from 165 (88) mg/d to 107 (89) mg/d (AMD, −58.5 mg/d; 95% CI, −71.6 to −45.4) in the no option arm (between-group AMD, −2.5 mg/d; 95% CI, −21.1 to 16.0).Conclusions and RelevanceIn this trial, outcomes did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage, but the proportion of participants who switched to buprenorphine was low.Trial RegistrationClinicalTrials.gov Identifier: NCT03026790

Older adults with rheumatoid arthritis (RA) treated with biologic disease-modifying antirheumatic drugs (bDMARDs), including anti-TNFs, are at an increased risk of serious infections and other adverse effects. Guidelines recommend de-escalating DMARDs for patients with low disease activity or remission to optimize the benefit-harm ratio of treatment. In a prior study, we observed that 20% of older adults with RA de-escalated anti-TNFs. This follow-up study examines the prevalence and factors associated with the re-escalation of treatment after anti-TNF de-escalation. We used 20% Medicare data from 2009-2017 to identify RA patients ≥66 years of age on anti-TNF therapy (Adalimumab, Etanercept, Certolizumab, or Golimumab), with de-escalation by cessation (> 90-day gap) or by taper (>50% effective dose reduction), and at least one rheumatologist visit pre- post-de-escalation (i.e. index-date). Re-escalation was defined as restarting the same anti-TNF or another bDMARD or increasing the effective dose by > 50% after the index date. Information on baseline patient characteristics, concomitant use of conventional synthetic DMARDs (csDMARDs), and changes in average glucocorticoids (GC) dose were collected. We identified 814 eligible Medicare beneficiaries, with an average age of 75.2 (SD 5.8), 84.5% female, 75.8% non-Hispanic white, and 43.4% with low-income subsidies (LIS). Of them, 61.1% re-escalated treatment with a median time of 160 (IQR 112-290) days since the index-date. In Cox analyses, re-escalation was more likely among blacks, Hispanics/others, and those with lower comorbidity burdens. Overall, more than half of older RA patients re-escalate treatment within a year of anti-TNF de-escalation highlights the importance of bDMARDs for disease control.

Importance:Patients prescribed long-term opioid therapy for chronic pain often experience unrelieved pain, poor quality of life, and serious adverse events. Objective:To compare the effects of integrated pain team (IPT) vs pharmacist collaborative management (PCM) on pain and opioid dosage. Design, Setting, and Participants:This study was a pragmatic multisite 12-month randomized comparative effectiveness trial with masked outcome assessment. Patients were recruited from October 2017 to March 2021; follow-up was completed June 2022. The study sites were Veterans Affairs primary care clinics. Eligible patients had moderate to severe chronic pain despite long-term opioid therapy (≥20 mg/d for at least 3 months). Interventions:IPT involved interdisciplinary pain care planning, visits throughout 12 months with medical and mental health clinicians, and emphasis on nondrug therapies and motivational interviewing. PCM was a collaborative care intervention involving visits throughout 12 months with a clinical pharmacist care manager who conducted structured monitoring and medication optimization. Both interventions provided individualized pain care and opioid tapering recommendations to patients. Main Outcomes and Measures:The primary outcome was pain response (≥30% decrease in Brief Pain Inventory total score) at 12 months. The main secondary outcome was 50% or greater reduction in opioid daily dosage at 12 months. Results:A total of 820 patients were randomized to IPT (n = 411) or PCM (n = 409). Participants' mean (SD) age was 62.2 (10.6) years, and 709 (86.5%) were male. A pain response was achieved in 58/350 patients in the IPT group (16.4%) vs 54/362 patients in the PCM group (14.9%) (odds ratio, 1.11 [95% CI, 0.74-1.67]; P = .61). A 50% opioid dose reduction was achieved in 102/403 patients in the IPT group (25.3%) vs 98/399 patients in the PCM group (24.6%) (odds ratio, 1.03 [95% CI, 0.75-1.42]; P = .85). Over 12 months, the mean (SD) Brief Pain Inventory total score improved from 6.7 (1.5) points to 6.1 (1.8) points (P < .001) in IPT and from 6.6 (1.6) points to 6.0 (1.9) points (P < .001) in PCM (between-group P = .82). Over 12 months, mean (SD) opioid daily dosage decreased from 80.8 (74.2) mg/d to 54.2 (65.0) mg/d in IPT (P < .001) and from 74.5 (56.9) mg/d to 52.8 (51.9) mg/d (P < .001) in PCM (between-group P = .22). Conclusions and Relevance:Outcomes in this randomized clinical trial did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage. Trial Registration:ClinicalTrials.gov Identifier: NCT03026790.

Nearly half of premature deaths can be prevented with healthy lifestyle behaviours. However, most older adults do not adhere to established guidelines to promote a healthy lifestyle. We propose a tailored framework of lifestyle medicine that acknowledges the complex contexts and care needs of older adults. The proposed framework of lifestyle medicine for older adults integrates their lived experiences (e.g. social determinants of health, built environment), the 5 M framework of geriatric medicine (i.e. Mind, Mobility, Medications, Multicomplexity, Matters Most) and the six pillars of lifestyle medicine (i.e. nutrition/diet, physical activity/exercise, restorative sleep, stress management, avoidance of risky substances, positive social connections) through a novel transdisciplinary approach. Guided by the updated framework, key gaps and opportunities are presented to advance lifestyle medicine practice, research and policy with the goal of promoting sustained behaviour change and improving the healthspan of older adults.

OBJECTIVE:Ageism (age-based stereotypes, prejudice, or discrimination) is prevalent and linked to prolonged disability and reduced lifespan in older adults. Little is known about ageism within rheumatology. This study explores the health care professional's (HCP) perception of the care of older adults and how ageist attitudes or perspectives may impact rheumatologic care. METHODS:A REDCap survey related to the clinical care of older adults that included the validated Expectations Regarding Aging (ERA-12) instrument (higher scores associated with less age-related bias) was administered to a convenience sample of HCP caring for patients with rheumatic disease. We calculated correlations between ERA-12 scores and the responses to other survey questions. RESULTS:A total of 255 surveys were collected from January 2023 to December 2023. Respondents were predominantly female (63%), White (70%), physicians (75%), healthcare professionals practicing in academic (66%) or in urban (64%) settings, and most practices having >25% adults over the age of 65 years (88%). The median ERA-12 score was 36 of 48, indicating that respondents, on average, disagreed with the stereotypes regarding aging. Higher ERA-12 scores were associated with greater enjoyment of the care of older adults (P < 0.001) and awareness of the Geriatric 5Ms (mind, mobility, medications, multicomplexity, and matters most (P < 0.001), a framework for improving age-friendly care. Lower ERA-12 scores were associated with believing that older adults are more demanding of attention (P < 0.001) and shifting from disease-modifying therapy to symptom relief in older adults (P < 0.001). CONCLUSION:Stereotypical beliefs regarding aging are associated with self-reported changes to patient counseling and medical decision-making, suggesting age-related biases may affect the care of older adults with rheumatic diseases.

OBJECTIVE:Transitioning from pediatric to adult care is challenging for adolescents with chronic health conditions. The Transition Readiness Assessment Questionnaire (TRAQ) is a validated tool for measuring transition readiness in pediatric patients with chronic diseases. This study examines the association of sociodemographic factors and primary diagnosis with transition readiness in adolescents with rheumatic disease using TRAQ scores. METHODS:We conducted a retrospective chart review of 882 adolescents with rheumatic diseases, aged 14 to 19 years, from September 2019 to December 2021. TRAQ scores, primary diagnosis, and demographic characteristics were collected. Bivariate and multiple linear regression analyses were used to identify predictors of transition readiness. RESULTS:We collected 882 TRAQs. Lupus diagnosis was significantly associated with higher TRAQ scores, whereas juvenile dermatomyositis diagnosis negatively influenced transition readiness. Non-Hispanic ethnicity correlated with higher scores in managing medications and tracking health issues, and male gender was significantly linked to lower scores in tracking health issues and managing daily activities. There was no association between TRAQ scores and age, race, primary language of the parent, insurance type, median household income, and suicidality screen. A total of 118 patients completed two TRAQs with a mean interval of 13.5 months. There was no significant change in TRAQ scores over time. However, Hispanic patients, patients with Spanish-speaking parents, and patients with lupus scored higher on the second TRAQ. CONCLUSION:In our cohort, transition readiness varied by primary diagnosis. Transition plans tailored to the needs of vulnerable adolescents are required to enhance health management skills and facilitate a successful transition.

BACKGROUND:To evaluate the associations between rheumatoid arthritis (RA) and all-cause (ACM) and cancer-Specific mortality (CSM) in older adults with bladder cancer and examine how frailty may affect these associations. METHODS:Retrospective cohort study derived from the Surveillance Epidemiology and End Results (SEER) cancer registry and linked to Medicare claims data (SEER-Medicare). The cohort consisted of patients ≥ 65 years diagnosed with bladder cancer between 2004 and 2017. RA and frailty status were derived using validated administrative algorithms. ACM and CSM as derived from the SEER registry. RESULTS:Frailty modified the relationship between RA and mortality outcomes (interaction P value for ACM: .002 and for CSM: .007). We observed that RA was associated with a higher risk of CSM (aHR 1.17, 95% CI, 1.01-1.35) and ACM (aHR 1.12, 95% CI, 1.05-1.20) in nonfrail patients. In frail patients with bladder cancer, RA was not independently associated with CSM (aHR 0.81, 95% CI, 0.62-1.06) or ACM (aHR 0.93, 95% CI, 0.83-1.05). CONCLUSION:Frailty is associated with adverse health outcomes. As people are living longer, it is becoming increasingly prevalent among patients with chronic conditions such as RA. We observed that RA is associated with increased risk of ACM and CSM among nonfrail older adults with bladder cancer. The lack of an association between RA and mortality in frail patients with RA suggests that the effect of frailty on mortality may overpower the effect that RA may exert-this information can help prognosticate outcomes in patients with bladder cancer, RA, and frailty.