Recent Publications by CFE Educators

We aimed to perform a structured literature review of spinal radiographic progression, as assessed by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), in patients with ankylosing spondylitis (AS) or nonradiographic axial spondyloarthritis (nr-axSpA) treated with biologic therapy. Searches were limited to English language manuscripts published in the 11 years prior to 9 July 2019. Randomized controlled trials, open-label extensions (OLEs) and observational studies reporting mSASSS progression in patients with AS or nr-axSpA treated with biologics were eligible for inclusion. Bias was assessed using the methodological index for nonrandomized studies (MINORS) tool. Among the 322 studies identified in the literature search, 23 (11 OLEs and 12 cohort studies) met the eligibility criteria and were selected for inclusion. Most studies reported mSASSS progression in patients with AS receiving tumor necrosis factor inhibitor (TNFi) treatment. One study reported mSASSS progression in patients with AS treated with secukinumab, an interleukin-17A inhibitor. The mean (range) MINORS score was 11.3 (7-15) for the 15 noncomparative studies and 15 (12-22) for the 8 comparative studies. Although results of the individual studies were variable, mSASSS progression in patients with AS was generally minimal and slow with long-term TNFi therapy. Moreover, odds ratios for the likelihood of mSASSS progression with/without TNFi favoured TNFi therapy in several of the cohort studies. The rate of mSASSS progression following continuous secukinumab treatment was low and remained stable over 4 years. Of two studies reporting progression in patients with nr-axSpA treated with TNFis, one showed no mSASSS progression; however, the lack of control limited comparative conclusions.

BACKGROUND

Despite increasing political will to achieve Universal Health Coverage (UHC), there is a paucity of empiric data describing what health system indicators are useful surrogates of country-level progress towards UHC. We sought to determine what public health interventions were useful tracers of country-level UHC progress.

METHODS

Across 183 countries we evaluated the extent to which 16 service delivery indicators explained variability in the UHC Service Coverage Index, (UHC SCI) a WHO-validated indicator of country-level health coverage. Dominance analyses, stratifying countries by World Bank income criteria, were used to determine which indicators were most important in in predicting UHC SCI scores.

FINDINGS

Health workforce density ranked first overall, provision of basic sanitation and access to clean water ranked second, and provision of basic antenatal services ranked third. In analysis stratified by World Bank income criteria, health workforce density ranked first in Lower Middle Income-Countries (LMICs) (n = 45) and third in Upper Middle Income-Countries (UMICs) (n = 51).

CONCLUSIONS

While each country will have a different approach to achieving UHC, strengthening the health workforce will need to be a key priority if they are to be successful in achieving UHC.

Sociologists have debated whether and how medical trainees are socialised to deal with uncertainty for decades. Recent changes in the structure of medical education, however, have likely affected the ways that resident physicians learn to manage uncertainty. Through ethnographic case studies of academic medical centres in Switzerland and the United States, this article provides new insights into the processes through which residents learnt to manage uncertainty. These processes included working under supervision, developing relationships of trust with supervisors and gaining autonomy to practise independently. As a result, residents developed different attitudes towards uncertainty. Residents at the Swiss medical centre tended to develop a more pragmatic attitude and viewed uncertainty as something to be addressed and controlled. On the other hand, residents at the American medical centre tended to develop an acceptive attitude towards uncertainty. More broadly, residents learnt to reproduce their supervisors' attitudes towards uncertainty. This article therefore provides new perspectives on continuity and the reproduction of social phenomena in medical education.

PURPOSE

The purpose of the study was to evaluate the effectiveness of ALDEA (Latinos con Diabetes en Acción), a Shared Medical Appointment (SMA) intervention, compared to usual primary care (UPC) for the treatment of adults with type 2 diabetes over a 6-month period. It was hypothesized that participants in the SMA will have greater reductions in A1C at 6 months post-intervention compared to the control group.

METHODS

This study was a quasi-experimental design with a non-randomized matched control group that followed participants prospectively for 6 months. All adults living with type-2 diabetes receiving primary care at a 2 FQHC clinics were eligible for inclusion. Participants in the control group were matched retrospectively on baseline A1C and age.

RESULTS

The reductions in A1C were greater in the ALDEA SMA intervention group relative to the UPC control group at 6 months in both of the FQHC centers and in the combined sample.

CONCLUSIONS

This study demonstrated that patients in the ALDEA program had a significantly greater reduction in A1C at 6 months compared to the control group. Despite its limitations, the ALDEA SMA program was successful in empowering patients and improving glycemic control.

BACKGROUND AND OBJECTIVE

Secukinumab, an anti-interleukin (IL)-17A monoclonal antibody, has demonstrated low radiographic progression over 4 years in patients with ankylosing spondylitis (AS). An adalimumab (tumor necrosis factor [TNF] inhibitor) biosimilar, GP2017 (SDZ-ADL; Sandoz), has been approved by the European Medicines Agency (July 2018) for use in all same indications as adalimumab, including AS. Adalimumab has also shown low long-term radiographic progression in patients with AS. Direct comparison of radiographic progression in AS between IL-17A and TNF inhibitors has not been studied. SURPASS is the first head-to-head, Phase IIIb, randomized, biologic-controlled study in AS to compare effects of secukinumab versus SDZ-ADL on spinal radiographic progression.

METHODS

Overall, 858 biologic-naïve patients with AS with elevated high-sensitivity C-reactive protein (≥ 5 mg/L) and/or at least one syndesmophyte in the cervical/lumbar spine at baseline (without total ankylosis) were randomized (1:1:1) to subcutaneous (sc) secukinumab (300 or 150 mg) or SDZ-ADL (40 mg). Secukinumab will be administered at baseline, weeks 1, 2, 3, and 4, and then every 4 weeks until week 100. SDZ-ADL will be administered every 2 weeks from baseline until week 102. Patients and investigators will be unblinded to drug but blinded to secukinumab doses. Spinal X-rays will be obtained at baseline, and weeks 52 and 104, sacroiliac joint (SIJ) X-rays at baseline and week 104, and magnetic resonance imaging (MRI) of SIJs and spine at baseline, weeks 16, 52, and 104. The primary endpoint is to demonstrate superiority of secukinumab (300 or 150 mg) treatment versus SDZ-ADL regarding proportion of patients with no radiographic progression (change from baseline in modified Stoke Ankylosing Spondylitis Spinal Score [mSASSS] ≤ 0.5) at week 104. Secondary endpoints include change from baseline in mSASSS, proportion of patients with syndesmophyte at baseline who develop no new syndesmophytes, reduction of osteitis on MRI of SIJs and spine (Berlin method). Assessment of SpondyloArthritis International Society (ASAS) 20/40 responses, ASAS partial remission, and AS Disease Activity Score (ASDAS) inactive disease (ASDAS  1.3) in secukinumab- versus SDZ-ADL-treated patients at week 104.

CONCLUSION

This is the first study designed to evaluate superiority of an IL-17A inhibitor, secukinumab, over a TNF inhibitor, SDZ-ADL, in reducing spinal radiographic progression in AS.

STUDY REGISTRATION

ClinicalTrials.gov, NCT03259074.

OBJECTIVE

To assess the attitudes and common practices of adult rheumatologists in the US regarding health care transition (HCT) for young adults with rheumatic diseases.

METHODS

An anonymous online survey was sent to US adult rheumatologist members of the American College of Rheumatology to collect demographic data and information on attitudes and common practices regarding the transition process.

RESULTS

Of 4,064 contacted rheumatologists, 203 (5%) completed the survey. Almost half of respondents (45.1%) were never trained in transition practices, and 74.7% were not familiar with the American Academy of Pediatrics/American Academy of Family Physicians/American College of Physicians Consensus Statement About Transitions for Youth with Special Healthcare Needs. Only 56.2% felt comfortable caring for former pediatric patients. The vast majority of respondents (90.7%) did not have a multidisciplinary transition team, and 37% did not have a plan for transitioning pediatric patients into their practice. Most adult rheumatologists were unsatisfied with the current transition process (92.9%), due to insufficient resources, personnel (91.1%), and time in clinic (86.9%). They also were unsatisfied with referral data received concerning previous treatments (48.9%), hospitalization history (48%), disease activity index (45.1%), medical history summary (43.9%), comorbidities (36.4%), medication list (34.1%), and disease classification (32.6%). Three major barriers to HCT were lack of insurance reimbursement (33.7%), knowledge about community resources (30.8%), and lapses in care between primary provider and specialist (27.8%).

CONCLUSION

This survey identified substantial gaps in knowledge and resources regarding HCT for young adults with rheumatic diseases. These may be best addressed by further training, research, dedicated resources, adequate payment, and practice guidelines.