The study found that such a program could be helpful to patients scheduled for a knee replacement, according to Iris Navarro-Millan, MD, MSPH, a rheumatologist at HSS who served as principal investigator. She presented the study at the American College of Rheumatology/Association of Rheumatology Professionals annual meeting on November 12 in Atlanta.

“On a national level, up to 30% of patients may have persistent pain after knee replacement surgery for osteoarthritis,” Dr. Navarro said. “One possible approach to improve outcomes is to optimize muscle strength, physical condition and mental preparation before surgery. Social cognitive theory posits that self-efficacy, peer or social support, sociocultural factors and expectations influence goals and outcomes.”

“There are successful programs in other areas of medicine, such as diabetes care, in which patient navigators share their experience and knowledge with their peers to help them better manage the disease,” said Lisa Mandl, MD, MPH, senior study author and a rheumatologist at HSS. “The thinking is that having the right mindset could optimize outcomes.”

The HSS researchers established focus groups of people who had a knee replacement at HSS to obtain information about their thoughts and experiences. The researchers sought to determine if a “pre-hab” program with trained peer coaches could be helpful and of interest to future patients scheduled for knee replacement surgery.

The investigators defined a peer coach as a patient who has already undergone knee replacement surgery and has been trained to provide personalized pre- and post-knee replacement support.

The 31 patients in the focus groups ranged in age from 65 to 89 and had had a knee replacement at HSS at least 12 months earlier with a good outcome. For almost half the patients, it was their second knee replacement, as they had undergone a previous surgery on their other leg.

“We asked patients about their challenges before and after knee replacement, potential barriers to accessing a pre-habilitation program and perspectives on what it might be like working with a peer coach to encourage exercise prior to knee replacement,” Dr. Navarro said.

The following themes emerged from the focus groups:

• Many patients with osteoarthritis delayed knee replacement for many years, often until the pain became very bad.
• Many weren’t sure of the best way to prepare for knee replacement surgery.
• They appreciated advice from other patients about preparation and recovery, and learning about the positive experiences of others often motivated them to have the surgery.
• The concept of peer coaches was well received.
• A few participants were already informally helping others scheduled for surgery and found it very rewarding.

The researchers concluded that preparation and expectations for surgery were influenced by patients’ own prior experience with a knee replacement, as well as by the experience of other patients who had already had the surgery.

“Patients with high outcome expectations who had had a previous knee replacement learned from their first experience and reported feeling motivated to engage in physical activity for muscle strengthening before their second knee replacement,” Dr. Navarro explained. “They expressed that their own experiences made them more informed, self-efficacious and physically active to prepare for their surgery.”

Patients who had had their first knee replacement reported that informally connecting with another individual who had already had the surgery was important in their decision to go ahead with the procedure, and also in preparing for it. They indicated that working with a peer coach would be beneficial for both preparation and recovery.

“Our findings suggest that formal peer-to-peer counseling that prepares patients for their first knee replacement surgery may hold promise to improve outcomes,” Dr. Navarro said. “Future studies could focus on the best way to establish such a program.”

Other study authors include Sarah R. Young, PhD (Binghamton University); Geyanne Lui, BS (Weill Cornell Medicine); Mariana B. Frey, BA (HSS); Janey C. Peterson, RN, MS, EdD (Weill Cornell Medicine); Susan M. Goodman, MD (HSS); and Monika M. Safford, MD (Weill Cornell Medicine).

Lead study author Susan M. Goodman, MD, a rheumatologist at HSS, said that while patients with rheumatic diseases are more prone to developing PJIs, it is also harder to make a PJI diagnosis in this population because many of the typical inflammation features of PJIs are similar to those seen in inflammatory arthritis flares. “If a patient with osteoarthritis comes in with a swollen and inflamed prosthetic joint, it is an infection until proven otherwise, but for patients with rheumatoid arthritis, it can be very hard to sort out whether this is part of an overall flare of disease or if it is a true infection,” she said. “None of the available tests are that helpful.”

The researchers launched the new study to examine the clinical and microbiological features of total hip and total knee arthroplasty PJIs in patients with rheumatic diseases and osteoarthritis. The researchers used the HSS institutional PJI registry to create a retrospective cohort of total hip/total knee replacement PJIs from 2009 to 2016. They identified 807 PJI cases, including 36 in patients with rheumatic disease and 771 in patients with osteoarthritis. Culture-negative cases were defined as PJIs with no evidence of microbial growth in intraoperative cultures; culture-positive PJIs were defined by positive microbial growth.

Among the findings, the researchers discovered that patients with rheumatic diseases had a higher proportion of culture-negative PJIs (27% vs 14%; P=0.02). “Patients with rheumatic diseases who were culture negative were less likely to meet the pathology criteria for infections than the ones who were culture positive, and they did a little worse,” said Dr. Goodman. One-year survivorship of culture-negative osteoarthritis and culture-negative rheumatic disease were 87% and 66%, respectively, and 47% for culture-positive rheumatic disease.

“The main message is that patients with rheumatic disease seem to have more culture-negative prosthetic joint infections than patients with osteoarthritis, but what we don’t know is what that means in terms of long-term management,” said Dr. Goodman. “We had the feeling that we were missing something with our rheumatic disease patients who were coming in with prosthetic joint infections, so I wasn’t surprised by our findings, but it pointed out how much more we need to do to really understand this.”

Dr. Goodman said the next step is to do a prospective study in patients with rheumatic disease, which will provide the standard diagnostic tests for PJIs but also use Next Generation Sequencing including cell-free DNA methods to better identify bacteria present in tissue.

The use of tranexamic acid has become widespread, as it has been associated with a lower rate of blood transfusions in osteoarthritis patients having joint replacement surgery. Investigators set out to determine if the use of TXA could also reduce transfusions for patients with rheumatoid arthritis having a hip or knee replacement. The researchers found that TXA was not associated with a lower transfusion rate in patients with RA. They concluded that pre-surgical optimization should include assessment and treatment of anemia in patients with RA who are scheduled for a total joint replacement.

Bella Mehta, MBBS, MS, a rheumatologist at Hospital for Special Surgery (HSS) in New York City, presented the findings at the American College of Rheumatology/Association of Rheumatology Professionals annual meeting on November 11 in Atlanta.

“With the aging of the population, elective total hip replacement has become one of the fastest-growing procedures to manage severe osteoarthritis,” said Dr. Mehta. “By 2030, the number of hip replacements is expected to reach 572,000 annually in the US. Medicare, the largest payer of joint replacement surgery, has introduced several payment reform models that target discharge destination and risk of hospital readmission after surgery. Our study examined how the socioeconomic status of the community in which one resides influences discharge destination and the odds of 90-day hospital readmission after hip replacement.”

Dr. Mehta noted that where a patient receives post-op care and rehab has a considerable impact on the total cost of hip replacement surgery. Previous studies have demonstrated significant variations in outcomes and costs due to individual factors such as race. There have been far fewer studies on the impact of community-level factors.

“Our study pushes the envelope by examining the role of where one lives in understanding variations in post-op care after elective joint replacement surgery. And it reflects the growing academic collaboration in clinical research between HSS and Weill Cornell Medicine investigators,” explained Said Ibrahim MD, MPH, MBA, senior investigator and chief of the Division of Healthcare Delivery Science and Innovation at Weill Cornell Medicine.

For the analysis, the investigators identified almost 85,000 patients in the Pennsylvania Health Care Cost Containment Council database who had elective hip replacement surgery between 2012 and 2016. The researchers used the Area Deprivation Index (ADI) from the American Census Survey, which reflects a geographic area’s level of socioeconomic deprivation and is associated with health outcomes.

In addition to discharge destination, the investigators assessed the risk of 90-day readmission for patients sent to a facility compared to those who received their post-op care and rehab at home. The researchers also assessed the interaction of race and ADI on outcomes.

The study found that patients from impoverished communities were more likely to be discharged to an institution compared to home after a hip replacement. The interaction effect of race and ADI on discharge destination was statistically significant in African American patients 65 years and older, but not in patients under 65 years old. The level of community deprivation did not have an effect on 90-day hospital readmission, nor did the interaction of ADI and race.

As a possible explanation for the study findings, Dr. Mehta noted that patients from impoverished communities may have less access to community-based services such as social support. Thus, discharge to a facility for post-operative and rehabilitative care might be perceived as a safer option in clinical decision-making.

“Our study is important because it advances our understanding of the relationship between health care and social determinants of health,” said Dr. Ibrahim. “Future studies should determine which specific community factors influence discharge destination and how they could be modified to allow more patients to go home after a hip replacement.”

Dr. Mehta added, “The ultimate goal of research is to design socially informed health policies to improve quality of care and outcomes.”

Susan M. Goodman, MD, and Michael L. Parks, MD, of HSS and Kaylee Ho, MS, of Weill Cornell Medicine were also involved in the study.

The investigators found that African American patients were at much higher risk of aseptic TKR revision than white patients, but that there were only modest racial disparities in the risk of septic TKR revision. Community poverty did not increase the risk of septic or aseptic TKR revision in either African Americans or whites.

Of note, low annual hospital TKR volume was a risk factor for septic TKR revision in both African American and white patients, and also increased the risk of aseptic TKR revision in white patients. Why the risk of aseptic revision was high for African Americans attending high TKR volume hospitals warrants further study, according to the researchers.

The findings were reported at the American College of Rheumatology/Association of Rheumatology Professionals annual meeting on November 11 in Atlanta.

“It is a misconception that lupus affects only women. Although most of those affected are female, studies show males represent an estimated 4 to 22% of patients,” explains Priscilla Toral, LCSW, program manager of Lupus Line^®/Charla de Lupus (Lupus Chat)^®, in the Department of Social Work Programs at HSS, which offers numerous support and education programs for people with lupus and their families. “Research has shown that the clinical presentation of lupus in men is very similar to what women experience. However, men often have more severe disease and tend to seek medical attention and supportive care less often than females.”

Limited research exists regarding the specific medical, psychosocial and support needs of men with lupus. Toral and colleagues at HSS set out to identify their self-reported needs and concerns, as well as their potential interest in support forums geared toward men.

An 85-question survey was disseminated nationally to males over 18 with lupus. The survey was advertised via online forums, at major hospitals serving lupus patients in New York City and through local and national lupus groups. The survey assessed four core areas: health status and quality of life, health behavior and lifestyle, access to care and interest in programs specifically designed for men. Participants completed the surveys via an online link.

A total of 112 respondents participated in the survey, with 61% identified as white, 21% as black/African-American, 15% as Hispanic and 31% as other. Mean age was 26 and mean time since diagnosis was 10 years. Forty-nine percent of males were employed/self-employed, while 46% were unemployed/unable to work. Fifty-three percent had an annual income of more than $50,000 and 59% had some college or an advanced degree. Ninety-four percent reported having health insurance. Almost all (92%) were being treated by a rheumatologist.

The researchers reported the following findings:

• In rating their overall health, 65% of respondents reported it as “fair/good” and 21% reported it as “poor.”
• The majority (76%) reported worrying more about their future since their diagnosis.
• Most (83%) reported that having lupus limits their activities of daily living. When asked about the single most important way it affected daily life, responses included fatigue and pain, with 48% reporting feeling pain daily.
• Fifty-three percent of respondents reported that lupus affects their sexual health, in the form of less sexual desire and satisfaction (52%), limited motion (45%), and impotence (47%).
• When asked if they feel comfortable talking with their doctor or rheumatologist about their sexual health, 70% of respondents strongly agreed/agreed.
• When asked if they have received education about or treatment for their sexual health, 69% of respondents reported that they had not.
• When asked how often they followed medical advice, 59% said always. The reasons for not following medical advice included worry about treatment side effects (44%) and that treatment would not help (43%).
• More than half (58%) reported feeling depressed for several days/more than half the days in the preceding two weeks.
• Regarding support and coping with lupus, 52% reported receiving no support, and 84% had never taken a class to learn self-management and coping skills.
• When asked if they would be interested in receiving support to help them cope, 40% were interested/very interested; 44% reported being unsure; and 15% were not interested.
• When asked about the type of support platform they would prefer, 77% indicated online; 71% a lupus app; 69% a social group; and 67% a support and education group.
• When asked how likely they would be to participate in a male-only support group, 50% reported likely/very likely; 27% unlikely/very unlikely; and 23% were unsure.

“This study provides important information about the physical and emotional health of males with lupus, as well as their interest in psychosocial support,” said Toral. “The next step would be to conduct focus groups to better understand their specific support needs, with the ultimate goal of developing programs to ensure those needs are being met.”

Additional study authors include Jillian Rose, PhD, MPH, LCSW; Roberta Horton, LCSW, ACSW; Ambar Tavera; and Natalia Irvine, MPH, all from HSS.

Investigators found that the incidence of dementia in patients with RA was as high or higher than previous reports from the general population. The presence of CVD in patients with RA increases the risk for dementia up to 2-fold when compared to RA patients without CVD or risk factors for CVD. The study suggests that in patients with RA, increasing risk for CVD may also be associated with an increased risk for dementia. The investigators wrote that further studies comparing patients with RA to those without RA are needed to clarify this association, as well as the impact of RA treatments, and primary and secondary CVD prevention.