MDedge Rheumatology

Nonradiographic axial spondyloarthritis (nr-axSpA) is a chronic, immune-mediated, inflammatory disease characterized by active inflammation of the spine and the sacroiliac joints. There is no cure for nr-axSpA, although tumor necrosis factor inhibitors (TNFi) have been established as the recommended standard treatment. Nevertheless, a considerable portion of patients either have an inadequate response to TNFi or are intolerant of the side effects of these agents. 

Dr Eric Ruderman, of Northwestern University Feinberg School of Medicine, Chicago, Illinois, discusses treatment goals for patients with active nr-axSpA, which include symptom control, preservation of function, and suppression of symptoms that interfere with daily activities. He also highlights treatment options for patients who have an inadequate response to or are intolerant of TNFi therapy. These therapies include interleukin-17 inhibitors (IL-17i), ixekizumab and secukinumab, and the Janus kinase inhibitor (JAKi) upadacitinib. 

IL-17i therapy carries a lower risk for infection compared with TNFi but is contraindicated in patients with irritable bowel disease. Dr Ruderman also notes that IL-17i are administered by subcutaneous injection while JAKi are taken orally, and these factors may influence patient preference.

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Eric M. Ruderman, MD, Professor, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; Associate Chief, Clinical Affairs, Department of Rheumatology, Northwestern Medical Group, Chicago, Illinois 

Eric M. Ruderman, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Amgen; Aurinia; Bristol Myers Squibb; Exagen; Janssen; Lilly; Novartis; Selecta 

Nonradiographic axial spondyloarthritis (nr-axSpA) is a chronic, immune-mediated, inflammatory disease characterized by active inflammation of the spine and the sacroiliac joints. There is no cure for nr-axSpA, although tumor necrosis factor inhibitors (TNFi) have been established as the recommended standard treatment. Nevertheless, a considerable portion of patients either have an inadequate response to TNFi or are intolerant of the side effects of these agents. 

Dr Eric Ruderman, of Northwestern University Feinberg School of Medicine, Chicago, Illinois, discusses treatment goals for patients with active nr-axSpA, which include symptom control, preservation of function, and suppression of symptoms that interfere with daily activities. He also highlights treatment options for patients who have an inadequate response to or are intolerant of TNFi therapy. These therapies include interleukin-17 inhibitors (IL-17i), ixekizumab and secukinumab, and the Janus kinase inhibitor (JAKi) upadacitinib. 

IL-17i therapy carries a lower risk for infection compared with TNFi but is contraindicated in patients with irritable bowel disease. Dr Ruderman also notes that IL-17i are administered by subcutaneous injection while JAKi are taken orally, and these factors may influence patient preference.

--

Eric M. Ruderman, MD, Professor, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; Associate Chief, Clinical Affairs, Department of Rheumatology, Northwestern Medical Group, Chicago, Illinois 

Eric M. Ruderman, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Amgen; Aurinia; Bristol Myers Squibb; Exagen; Janssen; Lilly; Novartis; Selecta 

Nonradiographic axial spondyloarthritis (nr-axSpA) is a chronic, immune-mediated, inflammatory disease characterized by active inflammation of the spine and the sacroiliac joints. There is no cure for nr-axSpA, although tumor necrosis factor inhibitors (TNFi) have been established as the recommended standard treatment. Nevertheless, a considerable portion of patients either have an inadequate response to TNFi or are intolerant of the side effects of these agents. 

Dr Eric Ruderman, of Northwestern University Feinberg School of Medicine, Chicago, Illinois, discusses treatment goals for patients with active nr-axSpA, which include symptom control, preservation of function, and suppression of symptoms that interfere with daily activities. He also highlights treatment options for patients who have an inadequate response to or are intolerant of TNFi therapy. These therapies include interleukin-17 inhibitors (IL-17i), ixekizumab and secukinumab, and the Janus kinase inhibitor (JAKi) upadacitinib. 

IL-17i therapy carries a lower risk for infection compared with TNFi but is contraindicated in patients with irritable bowel disease. Dr Ruderman also notes that IL-17i are administered by subcutaneous injection while JAKi are taken orally, and these factors may influence patient preference.

--

Eric M. Ruderman, MD, Professor, Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine; Associate Chief, Clinical Affairs, Department of Rheumatology, Northwestern Medical Group, Chicago, Illinois 

Eric M. Ruderman, MD, has disclosed the following relevant financial relationships: 

Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: AbbVie; Amgen; Aurinia; Bristol Myers Squibb; Exagen; Janssen; Lilly; Novartis; Selecta 

When OpenAI released ChatGPT-3 publicly last November, some doctors decided to try out the free AI tool that learns language and writes human-like text. Some physicians found the chatbot made mistakes and stopped using it, while others were happy with the results and plan to use it more often.

“We’ve played around with it. It was very early on in AI and we noticed it gave us incorrect information with regards to clinical guidance,” said Monalisa Tailor, MD, an internal medicine physician at Norton Health Care in Louisville, Ky. “We decided not to pursue it further,” she said.

Orthopedic spine surgeon Daniel Choi, MD, who owns a small medical/surgical practice in Long Island, New York, tested the chatbot’s performance with a few administrative tasks, including writing a job listing for an administrator and prior authorization letters.

He was enthusiastic. “A well-polished job posting that would usually take me 2-3 hours to write was done in 5 minutes,” Dr. Choi said. “I was blown away by the writing – it was much better than anything I could write.”

The chatbot can also automate administrative tasks in doctors’ practices from appointment scheduling and billing to clinical documentation, saving doctors time and money, experts say.

Most physicians are proceeding cautiously. About 10% of more than 500 medical group leaders, responding to a March poll by the Medical Group Management Association, said their practices regularly use AI tools.

More than half of the respondents not using AI said they first want more evidence that the technology works as intended.

“None of them work as advertised,” said one respondent.

MGMA practice management consultant Dawn Plested acknowledges that many of the physician practices she’s worked with are still wary. “I have yet to encounter a practice that is using any AI tool, even something as low-risk as appointment scheduling,” she said.

Physician groups may be concerned about the costs and logistics of integrating ChatGPT with their electronic health record systems (EHRs) and how that would work, said Ms. Plested.

Doctors may also be skeptical of AI based on their experience with EHRs, she said.

“They were promoted as a panacea to many problems; they were supposed to automate business practice, reduce staff and clinician’s work, and improve billing/coding/documentation. Unfortunately, they have become a major source of frustration for doctors,” said Ms. Plested.
 

Drawing the line at patient care

Patients are worried about their doctors relying on AI for their care, according to a Pew Research Center poll released in February. About 60% of U.S. adults say they would feel uncomfortable if their own health care professional relied on artificial intelligence to do things like diagnose disease and recommend treatments; about 40% say they would feel comfortable with this.

“We have not yet gone into using ChatGPT for clinical purposes and will be very cautious with these types of applications due to concerns about inaccuracies,” Dr. Choi said.

Practice leaders reported in the MGMA poll that the most common uses of AI were nonclinical, such as:

• Patient communications, including call center answering service to help triage calls, to sort/distribute incoming fax messages, and outreach such as appointment reminders and marketing materials.
• Capturing clinical documentation, often with natural language processing or speech recognition platforms to help virtually scribe.
• Improving billing operations and predictive analytics.

Some doctors told The New York Times that ChatGPT helped them communicate with patients in a more compassionate way.

They used chatbots “to find words to break bad news and express concerns about a patient’s suffering, or to just more clearly explain medical recommendations,” the story noted.
 

Is regulation needed?

Some legal scholars and medical groups say that AI should be regulated to protect patients and doctors from risks, including medical errors, that could harm patients.

“It’s very important to evaluate the accuracy, safety, and privacy of language learning models (LLMs) before integrating them into the medical system. The same should be true of any new medical tool,” said Mason Marks, MD, JD, a health law professor at the Florida State University College of Law in Tallahassee.

In mid-June, the American Medical Association approved two resolutions calling for greater government oversight of AI. The AMA will develop proposed state and federal regulations and work with the federal government and other organizations to protect patients from false or misleading AI-generated medical advice.

Dr. Marks pointed to existing federal rules that apply to AI. “The Federal Trade Commission already has regulation that can potentially be used to combat unfair or deceptive trade practices associated with chatbots,” he said.

In addition, “the U.S. Food and Drug Administration can also regulate these tools, but it needs to update how it approaches risk when it comes to AI. The FDA has an outdated view of risk as physical harm, for instance, from traditional medical devices. That view of risk needs to be updated and expanded to encompass the unique harms of AI,” Dr. Marks said.

There should also be more transparency about how LLM software is used in medicine, he said. “That could be a norm implemented by the LLM developers and it could also be enforced by federal agencies. For instance, the FDA could require developers to be more transparent regarding training data and methods, and the FTC could require greater transparency regarding how consumer data might be used and opportunities to opt out of certain uses,” said Dr. Marks.
 

What should doctors do?

Dr. Marks advised doctors to be cautious when using ChatGPT and other LLMs, especially for medical advice. “The same would apply to any new medical tool, but we know that the current generation of LLMs [is] particularly prone to making things up, which could lead to medical errors if relied on in clinical settings,” he said.

There is also potential for breaches of patient confidentiality if doctors input clinical information. ChatGPT and OpenAI-enabled tools may not be compliant with the Health Insurance Portability and Accountability Act, which set national standards to protect individuals’ medical records and individually identifiable health information.

“The best approach is to use chatbots cautiously and with skepticism. Don’t input patient information, confirm the accuracy of information produced, and don’t use them as replacements for professional judgment,” Dr. Marks recommended.

Ms. Plested suggested that doctors who want to experiment with AI start with a low-risk tool such as appointment reminders that could save staff time and money. “I never recommend they start with something as high-stakes as coding/billing,” she said.
 

A version of this article appeared on Medscape.com.

When OpenAI released ChatGPT-3 publicly last November, some doctors decided to try out the free AI tool that learns language and writes human-like text. Some physicians found the chatbot made mistakes and stopped using it, while others were happy with the results and plan to use it more often.

“We’ve played around with it. It was very early on in AI and we noticed it gave us incorrect information with regards to clinical guidance,” said Monalisa Tailor, MD, an internal medicine physician at Norton Health Care in Louisville, Ky. “We decided not to pursue it further,” she said.

Orthopedic spine surgeon Daniel Choi, MD, who owns a small medical/surgical practice in Long Island, New York, tested the chatbot’s performance with a few administrative tasks, including writing a job listing for an administrator and prior authorization letters.

He was enthusiastic. “A well-polished job posting that would usually take me 2-3 hours to write was done in 5 minutes,” Dr. Choi said. “I was blown away by the writing – it was much better than anything I could write.”

The chatbot can also automate administrative tasks in doctors’ practices from appointment scheduling and billing to clinical documentation, saving doctors time and money, experts say.

Most physicians are proceeding cautiously. About 10% of more than 500 medical group leaders, responding to a March poll by the Medical Group Management Association, said their practices regularly use AI tools.

More than half of the respondents not using AI said they first want more evidence that the technology works as intended.

“None of them work as advertised,” said one respondent.

MGMA practice management consultant Dawn Plested acknowledges that many of the physician practices she’s worked with are still wary. “I have yet to encounter a practice that is using any AI tool, even something as low-risk as appointment scheduling,” she said.

Physician groups may be concerned about the costs and logistics of integrating ChatGPT with their electronic health record systems (EHRs) and how that would work, said Ms. Plested.

Doctors may also be skeptical of AI based on their experience with EHRs, she said.

“They were promoted as a panacea to many problems; they were supposed to automate business practice, reduce staff and clinician’s work, and improve billing/coding/documentation. Unfortunately, they have become a major source of frustration for doctors,” said Ms. Plested.
 

Drawing the line at patient care

Patients are worried about their doctors relying on AI for their care, according to a Pew Research Center poll released in February. About 60% of U.S. adults say they would feel uncomfortable if their own health care professional relied on artificial intelligence to do things like diagnose disease and recommend treatments; about 40% say they would feel comfortable with this.

“We have not yet gone into using ChatGPT for clinical purposes and will be very cautious with these types of applications due to concerns about inaccuracies,” Dr. Choi said.

Practice leaders reported in the MGMA poll that the most common uses of AI were nonclinical, such as:

• Patient communications, including call center answering service to help triage calls, to sort/distribute incoming fax messages, and outreach such as appointment reminders and marketing materials.
• Capturing clinical documentation, often with natural language processing or speech recognition platforms to help virtually scribe.
• Improving billing operations and predictive analytics.

Some doctors told The New York Times that ChatGPT helped them communicate with patients in a more compassionate way.

They used chatbots “to find words to break bad news and express concerns about a patient’s suffering, or to just more clearly explain medical recommendations,” the story noted.
 

Is regulation needed?

Some legal scholars and medical groups say that AI should be regulated to protect patients and doctors from risks, including medical errors, that could harm patients.

“It’s very important to evaluate the accuracy, safety, and privacy of language learning models (LLMs) before integrating them into the medical system. The same should be true of any new medical tool,” said Mason Marks, MD, JD, a health law professor at the Florida State University College of Law in Tallahassee.

In mid-June, the American Medical Association approved two resolutions calling for greater government oversight of AI. The AMA will develop proposed state and federal regulations and work with the federal government and other organizations to protect patients from false or misleading AI-generated medical advice.

Dr. Marks pointed to existing federal rules that apply to AI. “The Federal Trade Commission already has regulation that can potentially be used to combat unfair or deceptive trade practices associated with chatbots,” he said.

In addition, “the U.S. Food and Drug Administration can also regulate these tools, but it needs to update how it approaches risk when it comes to AI. The FDA has an outdated view of risk as physical harm, for instance, from traditional medical devices. That view of risk needs to be updated and expanded to encompass the unique harms of AI,” Dr. Marks said.

There should also be more transparency about how LLM software is used in medicine, he said. “That could be a norm implemented by the LLM developers and it could also be enforced by federal agencies. For instance, the FDA could require developers to be more transparent regarding training data and methods, and the FTC could require greater transparency regarding how consumer data might be used and opportunities to opt out of certain uses,” said Dr. Marks.
 

What should doctors do?

Dr. Marks advised doctors to be cautious when using ChatGPT and other LLMs, especially for medical advice. “The same would apply to any new medical tool, but we know that the current generation of LLMs [is] particularly prone to making things up, which could lead to medical errors if relied on in clinical settings,” he said.

There is also potential for breaches of patient confidentiality if doctors input clinical information. ChatGPT and OpenAI-enabled tools may not be compliant with the Health Insurance Portability and Accountability Act, which set national standards to protect individuals’ medical records and individually identifiable health information.

“The best approach is to use chatbots cautiously and with skepticism. Don’t input patient information, confirm the accuracy of information produced, and don’t use them as replacements for professional judgment,” Dr. Marks recommended.

Ms. Plested suggested that doctors who want to experiment with AI start with a low-risk tool such as appointment reminders that could save staff time and money. “I never recommend they start with something as high-stakes as coding/billing,” she said.
 

A version of this article appeared on Medscape.com.

When OpenAI released ChatGPT-3 publicly last November, some doctors decided to try out the free AI tool that learns language and writes human-like text. Some physicians found the chatbot made mistakes and stopped using it, while others were happy with the results and plan to use it more often.

“We’ve played around with it. It was very early on in AI and we noticed it gave us incorrect information with regards to clinical guidance,” said Monalisa Tailor, MD, an internal medicine physician at Norton Health Care in Louisville, Ky. “We decided not to pursue it further,” she said.

Orthopedic spine surgeon Daniel Choi, MD, who owns a small medical/surgical practice in Long Island, New York, tested the chatbot’s performance with a few administrative tasks, including writing a job listing for an administrator and prior authorization letters.

He was enthusiastic. “A well-polished job posting that would usually take me 2-3 hours to write was done in 5 minutes,” Dr. Choi said. “I was blown away by the writing – it was much better than anything I could write.”

The chatbot can also automate administrative tasks in doctors’ practices from appointment scheduling and billing to clinical documentation, saving doctors time and money, experts say.

Most physicians are proceeding cautiously. About 10% of more than 500 medical group leaders, responding to a March poll by the Medical Group Management Association, said their practices regularly use AI tools.

More than half of the respondents not using AI said they first want more evidence that the technology works as intended.

“None of them work as advertised,” said one respondent.

MGMA practice management consultant Dawn Plested acknowledges that many of the physician practices she’s worked with are still wary. “I have yet to encounter a practice that is using any AI tool, even something as low-risk as appointment scheduling,” she said.

Physician groups may be concerned about the costs and logistics of integrating ChatGPT with their electronic health record systems (EHRs) and how that would work, said Ms. Plested.

Doctors may also be skeptical of AI based on their experience with EHRs, she said.

“They were promoted as a panacea to many problems; they were supposed to automate business practice, reduce staff and clinician’s work, and improve billing/coding/documentation. Unfortunately, they have become a major source of frustration for doctors,” said Ms. Plested.
 

Drawing the line at patient care

Patients are worried about their doctors relying on AI for their care, according to a Pew Research Center poll released in February. About 60% of U.S. adults say they would feel uncomfortable if their own health care professional relied on artificial intelligence to do things like diagnose disease and recommend treatments; about 40% say they would feel comfortable with this.

“We have not yet gone into using ChatGPT for clinical purposes and will be very cautious with these types of applications due to concerns about inaccuracies,” Dr. Choi said.

Practice leaders reported in the MGMA poll that the most common uses of AI were nonclinical, such as:

• Patient communications, including call center answering service to help triage calls, to sort/distribute incoming fax messages, and outreach such as appointment reminders and marketing materials.
• Capturing clinical documentation, often with natural language processing or speech recognition platforms to help virtually scribe.
• Improving billing operations and predictive analytics.

Some doctors told The New York Times that ChatGPT helped them communicate with patients in a more compassionate way.

They used chatbots “to find words to break bad news and express concerns about a patient’s suffering, or to just more clearly explain medical recommendations,” the story noted.
 

Is regulation needed?

Some legal scholars and medical groups say that AI should be regulated to protect patients and doctors from risks, including medical errors, that could harm patients.

“It’s very important to evaluate the accuracy, safety, and privacy of language learning models (LLMs) before integrating them into the medical system. The same should be true of any new medical tool,” said Mason Marks, MD, JD, a health law professor at the Florida State University College of Law in Tallahassee.

In mid-June, the American Medical Association approved two resolutions calling for greater government oversight of AI. The AMA will develop proposed state and federal regulations and work with the federal government and other organizations to protect patients from false or misleading AI-generated medical advice.

Dr. Marks pointed to existing federal rules that apply to AI. “The Federal Trade Commission already has regulation that can potentially be used to combat unfair or deceptive trade practices associated with chatbots,” he said.

In addition, “the U.S. Food and Drug Administration can also regulate these tools, but it needs to update how it approaches risk when it comes to AI. The FDA has an outdated view of risk as physical harm, for instance, from traditional medical devices. That view of risk needs to be updated and expanded to encompass the unique harms of AI,” Dr. Marks said.

There should also be more transparency about how LLM software is used in medicine, he said. “That could be a norm implemented by the LLM developers and it could also be enforced by federal agencies. For instance, the FDA could require developers to be more transparent regarding training data and methods, and the FTC could require greater transparency regarding how consumer data might be used and opportunities to opt out of certain uses,” said Dr. Marks.
 

What should doctors do?

Dr. Marks advised doctors to be cautious when using ChatGPT and other LLMs, especially for medical advice. “The same would apply to any new medical tool, but we know that the current generation of LLMs [is] particularly prone to making things up, which could lead to medical errors if relied on in clinical settings,” he said.

There is also potential for breaches of patient confidentiality if doctors input clinical information. ChatGPT and OpenAI-enabled tools may not be compliant with the Health Insurance Portability and Accountability Act, which set national standards to protect individuals’ medical records and individually identifiable health information.

“The best approach is to use chatbots cautiously and with skepticism. Don’t input patient information, confirm the accuracy of information produced, and don’t use them as replacements for professional judgment,” Dr. Marks recommended.

Ms. Plested suggested that doctors who want to experiment with AI start with a low-risk tool such as appointment reminders that could save staff time and money. “I never recommend they start with something as high-stakes as coding/billing,” she said.
 

A version of this article appeared on Medscape.com.

After her emergency medicine group was acquired by a staffing firm backed by a large private equity (PE) firm, Michelle Wiener, MD, said the workflow changes came swiftly.

“Our staffing has been greatly reduced,” the Detroit physician said. “At this point, we have no say in anything. We have no say in the scheduling. We aren’t allowed to see what is billed under our name. The morale has really gone down.”

Dr. Wiener, who practices at Ascension St. John Hospital, said she and fellow physicians have repeatedly brought their concerns to TeamHealth, which in 2015 took over St. John Emergency Services PC. TeamHealth is owned by PE giant Blackstone.

“It’s very frustrating,” Dr. Wiener said. “We’re taking it from all sides.”

Blackstone and Ascension St. John did not respond to this news organization’s request for comment.

TeamHealth would not respond directly to questions about the Ascension St. John Hospital physicians or their concerns.

Spokesman Josh Hopson provided only a general statement: “TeamHealth is committed to making sure that clinicians have the resources and support needed to provide first-class care to patients, particularly with regard to staffing and compensation. TeamHealth has and will always put patient care first, and that is not impacted by its ownership model.”

Acquisitions of medical practices and hospitals by PE firms are rapidly growing, with more than 1,400 PE deals in health care in 2021 totaling upwards of $208 billion, according to PitchBook Data Inc., a Seattle-based firm that tracks mergers and acquisitions.

Some physicians praise the partnerships as an opportunity to improve technology and efficiency, whereas others decry them as raising patient costs and lowering the quality of care. A recent UC Berkeley study found that PE ownership of medical practices was linked to consumer price increases for 8 of 10 specialties, most notably oncology and gastroenterology.
 

What should you expect after PE acquisition?

Since his practice partnered with a PE firm in 2020, Milwaukee-based otolaryngologist Madan Kandula, MD, said he has found the changes positive. The practice has grown and improved operations in finance, accounting, compliance, and information technology, said Dr. Kandula, founder and CEO of Advent, an ENT practice with 15 clinics in four Midwestern states.

Dr. Kandula said his group already had a sound business practice, and that the goal of partnering with a PE firm wasn’t to change day-to-day operations but to propel the organization forward.

“From patient load to visit time to how we staff our clinics, there has been no change,” he said. “My private equity firm does not, [and] cannot, impose their will on our clinical decisions.”

Experts say the impact of PE acquisitions on individual physicians often depends on where a doctor ranks in the organization, what stage they are in their career, and how much control they had over the deal.

“It’s the older physicians who are usually selling the practice and getting the big payout,” said Anjali Dooley, a St. Louis–based health law attorney who counsels physicians about PE deals. “The younger doctors are usually not part of the deal, as they may still be employees. They don’t have any negotiating power. Hopefully, there is some transparency, but sometimes there is not, and they are blindsided by the deal.”

When it comes to workload, most PE-owned groups are put on a production-based model, such as a wRVU-based model, said Roger Strode, a Chicago-based health law attorney who focuses on health care mergers and acquisitions. Most already operate under such a model, but there might be some changes after a buyout.

Staffing may also change, added Ms. Dooley. The PE firms may want to add partners or companies already in their portfolios to create efficiencies, causing training or workflow changes.

In a hospital buyout, changes may depend on whether a department is a significant revenue generator for the hospital, Ms. Dooley noted.

PE firms frequently favor higher revenue–generating specialties, such as neurosurgery, cardiology, orthopedics, gastroenterology, and plastic surgery. They closely scrutinize departments said that make less money, such as the emergency department or primary care, Ms. Dooley said. Physicians or teams that don’t fit the firm’s cost-efficiency plans may be terminated or replaced.

On the other hand, Mr. Strode said physicians may see improved electronic health records and collections.

“Some of your overall overhead costs may be reduced, because they’re better at it,” Mr. Strode said. “When you’ve got more scale, the cost per patient, the cost per hour, the cost per procedure, goes down, and the cost that’s applied against your production will go down. As [practices grow], they have more bargaining power with payers and you can potentially get better rates. At least, that’s the promise.”

Analysts note that PE health care acquisitions show no signs of slowing and that it pays for physicians to know what to expect and how to cope if their practice or hospital is acquired. Whether physicians have some control over a buyout or are blindsided by the transition, it’s critical to know what to consider, how workloads might change, and your options for settling in or settling up.

The PE industry has about $2 trillion lined up for potential investments in 2023, said Ms. Dooley.

“PE firms are looking at health care to expend some of this dry powder,” Ms. Dooley continued. “If done correctly, PE firms that are aware of health care regulations, compliance, and patient care issues can ... remove redundant services and improve ... efficiencies, but the bad is when that doesn’t happen, and the quality of care goes down or there are patient safety risks.”
 

How to prepare for and cope with PE partnerships

If your practice is considering a PE partnership, it’s important to explore the terms and conditions and carefully weigh the pros and cons, said Gary Herschman, a Newark, N.J.–based attorney who advises PE-owned physician groups.

“My recommendation is that physicians at a minimum conduct due diligence on all potential strategic options for their groups, and then make an informed decision regarding whether a partnership transaction is right for their group, as it’s not right for every group,” he said.

When Texas cardiologist Rick Snyder, MD, was considering PE partnerships, he spoke with physicians who made similar deals to determine whether they were satisfied years later, he said. In April, Snyder’s practice, HeartPlace, the largest physician-owned cardiology practice in Texas, was acquired by US Heart & Vascular, a practice management platform backed by PE firm Ares Management.

“I called every group that I knew that had done private equity for any meaningful amount of time,” Dr. Snyder said. “For the first year or two, everybody is in the honeymoon period. If the model is going to succeed or break down, it’s not going to be in the first year or two. So I wanted to talk to groups that had done this for a longer amount of time and find out what their pitfalls were. What would they have done differently? Has it been a productive relationship? Did they grow?”

Dr. Snyder, president of the Texas Medical Association, said his practice met with seven or eight firms before choosing one that best met their needs. His group wanted a platform that preserved their clinical autonomy, governance, and culture, he said. They also wanted to ensure they were not entering into a “buy and flip” scenario, but rather a “buy and build” plan.

“Thus, financial capital was not sufficient, they also had to have intellectual capital and relationship capital on their bench,” he said. “When we found the partner that embraced all of these factors as well as a history of buying and long-term building, we pulled the trigger and partnered with Ares and US Heart & Vascular Management. The partner we chose did not offer us the most money. We put a premium on these other criteria.”

“I always tell docs, know the culture of your group and your vision,” he said. “Before you go down that route, ask yourself what you want to accomplish and if it makes sense having a private equity partner to accomplish that vision with.”

For younger physicians or those with little control over buyouts, experts recommend they review their contracts and consider consulting with an attorney to better understand how the deal may affect their earnings and career prospects.

Those who have a much longer career runway need to weigh whether they want to work for a PE-linked practice, Mr. Strode said. For some, it’s time to check when their noncompete agreements end and find a position elsewhere.

Also, physicians should know their rights and the laws in their states regarding the corporate practice of medicine. Statutes vary by state, and knowing the provisions in your state helps doctors recognize their legal rights, learn possible exceptions to the requirements, and know the penalties for violations.

In Michigan, a group of physicians and other health professionals at Ascension St. John has voted to unionize. Doctors hope that the union, which includes advanced practice clinicians, nurse practitioners, and physician assistants, will help improve patient care and protect working conditions for staff, Dr. Wiener said.

She advises physicians who are unhappy after acquisitions to speak up and stick together.

“That’s the biggest thing I think physicians should start doing,” she said. “Support each other and stand up. You are stronger together.”
 

Why is PE so attracted to health care?

PE firms typically buy practices or hospitals, work to make the entities more profitable, and then sell them, with the goal of doubling or tripling their investment over a short period. In general, PE firms aim for annual returns exceeding 20% after 3-7 years.

These firms know that health care is relatively recession-proof, that providers have third-party payers, and that the industry is fragmented and requires more efficiency, Ms. Dooley said.

When PE practice acquisitions started gaining momentum about 12 years ago, traditional hospital-based specialties such as anesthesiology and radiology were prime targets, said Mr. Strode.

At the same time, increasing challenges in private practice, such as declining compensation from payers, pressure to participate in value-based care programs, and rising regional competitors have fueled more physician groups to partner with PE firms, Mr. Herschman noted.

Physicians who partner with PE firms often benefit by having new access to capital to grow their practices, cost savings through group purchasing, and the ability to compete with larger health groups, Mr. Herschman said.

Questions remain, however, about how PE involvement affects health care use and spending. An April 2023 JAMA Viewpoint article called out the lack of oversight and regulation in the health care/PE space, suggesting that a stronger framework for regulation and transparency is needed.

A 2022 study in JAMA Health Forum that examined changes in prices and utilization associated with the PE acquisitions of 578 dermatology, gastroenterology, and ophthalmology physician practices from 2016 to 2020 found that prices increased by an average of 11%, and volume rose by 16%, after acquisition.

“We found that acquisitions were associated with increases in health care spending and utilization, as well as some other patterns of care like potential upcoding,” said Jane M. Zhu, MD, an author of the study and assistant professor at Oregon Health & Science University in Portland.

Another recent study that Dr. Zhu coauthored, published in Health Affairs, found that physician practices acquired by PE firms experience greater staff turnover and rely more heavily on advanced practice professionals than doctors.

“To the extent that that turnover indicates physicians are dissatisfied after private equity comes in, that’s really important to investigate further,” Dr. Zhu said.

PE firms owned 4% of U.S. hospitals in 2021 and 11% of nursing homes, according to a Medicare Payment Advisory Commission (MedPAC) report. The report does not include 2021 data on medical practices but notes that from 2013 to 2016, PE firms acquired at least 2% of physician practices. Estimates of PE deals are probably lower than actual numbers because of the lack of comprehensive information sources, according to the MedPAC report.

A version of this article appeared on Medscape.com.

After her emergency medicine group was acquired by a staffing firm backed by a large private equity (PE) firm, Michelle Wiener, MD, said the workflow changes came swiftly.

“Our staffing has been greatly reduced,” the Detroit physician said. “At this point, we have no say in anything. We have no say in the scheduling. We aren’t allowed to see what is billed under our name. The morale has really gone down.”

Dr. Wiener, who practices at Ascension St. John Hospital, said she and fellow physicians have repeatedly brought their concerns to TeamHealth, which in 2015 took over St. John Emergency Services PC. TeamHealth is owned by PE giant Blackstone.

“It’s very frustrating,” Dr. Wiener said. “We’re taking it from all sides.”

Blackstone and Ascension St. John did not respond to this news organization’s request for comment.

TeamHealth would not respond directly to questions about the Ascension St. John Hospital physicians or their concerns.

Spokesman Josh Hopson provided only a general statement: “TeamHealth is committed to making sure that clinicians have the resources and support needed to provide first-class care to patients, particularly with regard to staffing and compensation. TeamHealth has and will always put patient care first, and that is not impacted by its ownership model.”

Acquisitions of medical practices and hospitals by PE firms are rapidly growing, with more than 1,400 PE deals in health care in 2021 totaling upwards of $208 billion, according to PitchBook Data Inc., a Seattle-based firm that tracks mergers and acquisitions.

Some physicians praise the partnerships as an opportunity to improve technology and efficiency, whereas others decry them as raising patient costs and lowering the quality of care. A recent UC Berkeley study found that PE ownership of medical practices was linked to consumer price increases for 8 of 10 specialties, most notably oncology and gastroenterology.
 

What should you expect after PE acquisition?

Since his practice partnered with a PE firm in 2020, Milwaukee-based otolaryngologist Madan Kandula, MD, said he has found the changes positive. The practice has grown and improved operations in finance, accounting, compliance, and information technology, said Dr. Kandula, founder and CEO of Advent, an ENT practice with 15 clinics in four Midwestern states.

Dr. Kandula said his group already had a sound business practice, and that the goal of partnering with a PE firm wasn’t to change day-to-day operations but to propel the organization forward.

“From patient load to visit time to how we staff our clinics, there has been no change,” he said. “My private equity firm does not, [and] cannot, impose their will on our clinical decisions.”

Experts say the impact of PE acquisitions on individual physicians often depends on where a doctor ranks in the organization, what stage they are in their career, and how much control they had over the deal.

“It’s the older physicians who are usually selling the practice and getting the big payout,” said Anjali Dooley, a St. Louis–based health law attorney who counsels physicians about PE deals. “The younger doctors are usually not part of the deal, as they may still be employees. They don’t have any negotiating power. Hopefully, there is some transparency, but sometimes there is not, and they are blindsided by the deal.”

When it comes to workload, most PE-owned groups are put on a production-based model, such as a wRVU-based model, said Roger Strode, a Chicago-based health law attorney who focuses on health care mergers and acquisitions. Most already operate under such a model, but there might be some changes after a buyout.

Staffing may also change, added Ms. Dooley. The PE firms may want to add partners or companies already in their portfolios to create efficiencies, causing training or workflow changes.

In a hospital buyout, changes may depend on whether a department is a significant revenue generator for the hospital, Ms. Dooley noted.

PE firms frequently favor higher revenue–generating specialties, such as neurosurgery, cardiology, orthopedics, gastroenterology, and plastic surgery. They closely scrutinize departments said that make less money, such as the emergency department or primary care, Ms. Dooley said. Physicians or teams that don’t fit the firm’s cost-efficiency plans may be terminated or replaced.

On the other hand, Mr. Strode said physicians may see improved electronic health records and collections.

“Some of your overall overhead costs may be reduced, because they’re better at it,” Mr. Strode said. “When you’ve got more scale, the cost per patient, the cost per hour, the cost per procedure, goes down, and the cost that’s applied against your production will go down. As [practices grow], they have more bargaining power with payers and you can potentially get better rates. At least, that’s the promise.”

Analysts note that PE health care acquisitions show no signs of slowing and that it pays for physicians to know what to expect and how to cope if their practice or hospital is acquired. Whether physicians have some control over a buyout or are blindsided by the transition, it’s critical to know what to consider, how workloads might change, and your options for settling in or settling up.

The PE industry has about $2 trillion lined up for potential investments in 2023, said Ms. Dooley.

“PE firms are looking at health care to expend some of this dry powder,” Ms. Dooley continued. “If done correctly, PE firms that are aware of health care regulations, compliance, and patient care issues can ... remove redundant services and improve ... efficiencies, but the bad is when that doesn’t happen, and the quality of care goes down or there are patient safety risks.”
 

How to prepare for and cope with PE partnerships

If your practice is considering a PE partnership, it’s important to explore the terms and conditions and carefully weigh the pros and cons, said Gary Herschman, a Newark, N.J.–based attorney who advises PE-owned physician groups.

“My recommendation is that physicians at a minimum conduct due diligence on all potential strategic options for their groups, and then make an informed decision regarding whether a partnership transaction is right for their group, as it’s not right for every group,” he said.

When Texas cardiologist Rick Snyder, MD, was considering PE partnerships, he spoke with physicians who made similar deals to determine whether they were satisfied years later, he said. In April, Snyder’s practice, HeartPlace, the largest physician-owned cardiology practice in Texas, was acquired by US Heart & Vascular, a practice management platform backed by PE firm Ares Management.

“I called every group that I knew that had done private equity for any meaningful amount of time,” Dr. Snyder said. “For the first year or two, everybody is in the honeymoon period. If the model is going to succeed or break down, it’s not going to be in the first year or two. So I wanted to talk to groups that had done this for a longer amount of time and find out what their pitfalls were. What would they have done differently? Has it been a productive relationship? Did they grow?”

Dr. Snyder, president of the Texas Medical Association, said his practice met with seven or eight firms before choosing one that best met their needs. His group wanted a platform that preserved their clinical autonomy, governance, and culture, he said. They also wanted to ensure they were not entering into a “buy and flip” scenario, but rather a “buy and build” plan.

“Thus, financial capital was not sufficient, they also had to have intellectual capital and relationship capital on their bench,” he said. “When we found the partner that embraced all of these factors as well as a history of buying and long-term building, we pulled the trigger and partnered with Ares and US Heart & Vascular Management. The partner we chose did not offer us the most money. We put a premium on these other criteria.”

“I always tell docs, know the culture of your group and your vision,” he said. “Before you go down that route, ask yourself what you want to accomplish and if it makes sense having a private equity partner to accomplish that vision with.”

For younger physicians or those with little control over buyouts, experts recommend they review their contracts and consider consulting with an attorney to better understand how the deal may affect their earnings and career prospects.

Those who have a much longer career runway need to weigh whether they want to work for a PE-linked practice, Mr. Strode said. For some, it’s time to check when their noncompete agreements end and find a position elsewhere.

Also, physicians should know their rights and the laws in their states regarding the corporate practice of medicine. Statutes vary by state, and knowing the provisions in your state helps doctors recognize their legal rights, learn possible exceptions to the requirements, and know the penalties for violations.

In Michigan, a group of physicians and other health professionals at Ascension St. John has voted to unionize. Doctors hope that the union, which includes advanced practice clinicians, nurse practitioners, and physician assistants, will help improve patient care and protect working conditions for staff, Dr. Wiener said.

She advises physicians who are unhappy after acquisitions to speak up and stick together.

“That’s the biggest thing I think physicians should start doing,” she said. “Support each other and stand up. You are stronger together.”
 

Why is PE so attracted to health care?

PE firms typically buy practices or hospitals, work to make the entities more profitable, and then sell them, with the goal of doubling or tripling their investment over a short period. In general, PE firms aim for annual returns exceeding 20% after 3-7 years.

These firms know that health care is relatively recession-proof, that providers have third-party payers, and that the industry is fragmented and requires more efficiency, Ms. Dooley said.

When PE practice acquisitions started gaining momentum about 12 years ago, traditional hospital-based specialties such as anesthesiology and radiology were prime targets, said Mr. Strode.

At the same time, increasing challenges in private practice, such as declining compensation from payers, pressure to participate in value-based care programs, and rising regional competitors have fueled more physician groups to partner with PE firms, Mr. Herschman noted.

Physicians who partner with PE firms often benefit by having new access to capital to grow their practices, cost savings through group purchasing, and the ability to compete with larger health groups, Mr. Herschman said.

Questions remain, however, about how PE involvement affects health care use and spending. An April 2023 JAMA Viewpoint article called out the lack of oversight and regulation in the health care/PE space, suggesting that a stronger framework for regulation and transparency is needed.

A 2022 study in JAMA Health Forum that examined changes in prices and utilization associated with the PE acquisitions of 578 dermatology, gastroenterology, and ophthalmology physician practices from 2016 to 2020 found that prices increased by an average of 11%, and volume rose by 16%, after acquisition.

“We found that acquisitions were associated with increases in health care spending and utilization, as well as some other patterns of care like potential upcoding,” said Jane M. Zhu, MD, an author of the study and assistant professor at Oregon Health & Science University in Portland.

Another recent study that Dr. Zhu coauthored, published in Health Affairs, found that physician practices acquired by PE firms experience greater staff turnover and rely more heavily on advanced practice professionals than doctors.

“To the extent that that turnover indicates physicians are dissatisfied after private equity comes in, that’s really important to investigate further,” Dr. Zhu said.

PE firms owned 4% of U.S. hospitals in 2021 and 11% of nursing homes, according to a Medicare Payment Advisory Commission (MedPAC) report. The report does not include 2021 data on medical practices but notes that from 2013 to 2016, PE firms acquired at least 2% of physician practices. Estimates of PE deals are probably lower than actual numbers because of the lack of comprehensive information sources, according to the MedPAC report.

A version of this article appeared on Medscape.com.

After her emergency medicine group was acquired by a staffing firm backed by a large private equity (PE) firm, Michelle Wiener, MD, said the workflow changes came swiftly.

“Our staffing has been greatly reduced,” the Detroit physician said. “At this point, we have no say in anything. We have no say in the scheduling. We aren’t allowed to see what is billed under our name. The morale has really gone down.”

Dr. Wiener, who practices at Ascension St. John Hospital, said she and fellow physicians have repeatedly brought their concerns to TeamHealth, which in 2015 took over St. John Emergency Services PC. TeamHealth is owned by PE giant Blackstone.

“It’s very frustrating,” Dr. Wiener said. “We’re taking it from all sides.”

Blackstone and Ascension St. John did not respond to this news organization’s request for comment.

TeamHealth would not respond directly to questions about the Ascension St. John Hospital physicians or their concerns.

Spokesman Josh Hopson provided only a general statement: “TeamHealth is committed to making sure that clinicians have the resources and support needed to provide first-class care to patients, particularly with regard to staffing and compensation. TeamHealth has and will always put patient care first, and that is not impacted by its ownership model.”

Acquisitions of medical practices and hospitals by PE firms are rapidly growing, with more than 1,400 PE deals in health care in 2021 totaling upwards of $208 billion, according to PitchBook Data Inc., a Seattle-based firm that tracks mergers and acquisitions.

Some physicians praise the partnerships as an opportunity to improve technology and efficiency, whereas others decry them as raising patient costs and lowering the quality of care. A recent UC Berkeley study found that PE ownership of medical practices was linked to consumer price increases for 8 of 10 specialties, most notably oncology and gastroenterology.
 

What should you expect after PE acquisition?

Since his practice partnered with a PE firm in 2020, Milwaukee-based otolaryngologist Madan Kandula, MD, said he has found the changes positive. The practice has grown and improved operations in finance, accounting, compliance, and information technology, said Dr. Kandula, founder and CEO of Advent, an ENT practice with 15 clinics in four Midwestern states.

Dr. Kandula said his group already had a sound business practice, and that the goal of partnering with a PE firm wasn’t to change day-to-day operations but to propel the organization forward.

“From patient load to visit time to how we staff our clinics, there has been no change,” he said. “My private equity firm does not, [and] cannot, impose their will on our clinical decisions.”

Experts say the impact of PE acquisitions on individual physicians often depends on where a doctor ranks in the organization, what stage they are in their career, and how much control they had over the deal.

“It’s the older physicians who are usually selling the practice and getting the big payout,” said Anjali Dooley, a St. Louis–based health law attorney who counsels physicians about PE deals. “The younger doctors are usually not part of the deal, as they may still be employees. They don’t have any negotiating power. Hopefully, there is some transparency, but sometimes there is not, and they are blindsided by the deal.”

When it comes to workload, most PE-owned groups are put on a production-based model, such as a wRVU-based model, said Roger Strode, a Chicago-based health law attorney who focuses on health care mergers and acquisitions. Most already operate under such a model, but there might be some changes after a buyout.

Staffing may also change, added Ms. Dooley. The PE firms may want to add partners or companies already in their portfolios to create efficiencies, causing training or workflow changes.

In a hospital buyout, changes may depend on whether a department is a significant revenue generator for the hospital, Ms. Dooley noted.

PE firms frequently favor higher revenue–generating specialties, such as neurosurgery, cardiology, orthopedics, gastroenterology, and plastic surgery. They closely scrutinize departments said that make less money, such as the emergency department or primary care, Ms. Dooley said. Physicians or teams that don’t fit the firm’s cost-efficiency plans may be terminated or replaced.

On the other hand, Mr. Strode said physicians may see improved electronic health records and collections.

“Some of your overall overhead costs may be reduced, because they’re better at it,” Mr. Strode said. “When you’ve got more scale, the cost per patient, the cost per hour, the cost per procedure, goes down, and the cost that’s applied against your production will go down. As [practices grow], they have more bargaining power with payers and you can potentially get better rates. At least, that’s the promise.”

Analysts note that PE health care acquisitions show no signs of slowing and that it pays for physicians to know what to expect and how to cope if their practice or hospital is acquired. Whether physicians have some control over a buyout or are blindsided by the transition, it’s critical to know what to consider, how workloads might change, and your options for settling in or settling up.

The PE industry has about $2 trillion lined up for potential investments in 2023, said Ms. Dooley.

“PE firms are looking at health care to expend some of this dry powder,” Ms. Dooley continued. “If done correctly, PE firms that are aware of health care regulations, compliance, and patient care issues can ... remove redundant services and improve ... efficiencies, but the bad is when that doesn’t happen, and the quality of care goes down or there are patient safety risks.”
 

How to prepare for and cope with PE partnerships

If your practice is considering a PE partnership, it’s important to explore the terms and conditions and carefully weigh the pros and cons, said Gary Herschman, a Newark, N.J.–based attorney who advises PE-owned physician groups.

“My recommendation is that physicians at a minimum conduct due diligence on all potential strategic options for their groups, and then make an informed decision regarding whether a partnership transaction is right for their group, as it’s not right for every group,” he said.

When Texas cardiologist Rick Snyder, MD, was considering PE partnerships, he spoke with physicians who made similar deals to determine whether they were satisfied years later, he said. In April, Snyder’s practice, HeartPlace, the largest physician-owned cardiology practice in Texas, was acquired by US Heart & Vascular, a practice management platform backed by PE firm Ares Management.

“I called every group that I knew that had done private equity for any meaningful amount of time,” Dr. Snyder said. “For the first year or two, everybody is in the honeymoon period. If the model is going to succeed or break down, it’s not going to be in the first year or two. So I wanted to talk to groups that had done this for a longer amount of time and find out what their pitfalls were. What would they have done differently? Has it been a productive relationship? Did they grow?”

Dr. Snyder, president of the Texas Medical Association, said his practice met with seven or eight firms before choosing one that best met their needs. His group wanted a platform that preserved their clinical autonomy, governance, and culture, he said. They also wanted to ensure they were not entering into a “buy and flip” scenario, but rather a “buy and build” plan.

“Thus, financial capital was not sufficient, they also had to have intellectual capital and relationship capital on their bench,” he said. “When we found the partner that embraced all of these factors as well as a history of buying and long-term building, we pulled the trigger and partnered with Ares and US Heart & Vascular Management. The partner we chose did not offer us the most money. We put a premium on these other criteria.”

“I always tell docs, know the culture of your group and your vision,” he said. “Before you go down that route, ask yourself what you want to accomplish and if it makes sense having a private equity partner to accomplish that vision with.”

For younger physicians or those with little control over buyouts, experts recommend they review their contracts and consider consulting with an attorney to better understand how the deal may affect their earnings and career prospects.

Those who have a much longer career runway need to weigh whether they want to work for a PE-linked practice, Mr. Strode said. For some, it’s time to check when their noncompete agreements end and find a position elsewhere.

Also, physicians should know their rights and the laws in their states regarding the corporate practice of medicine. Statutes vary by state, and knowing the provisions in your state helps doctors recognize their legal rights, learn possible exceptions to the requirements, and know the penalties for violations.

In Michigan, a group of physicians and other health professionals at Ascension St. John has voted to unionize. Doctors hope that the union, which includes advanced practice clinicians, nurse practitioners, and physician assistants, will help improve patient care and protect working conditions for staff, Dr. Wiener said.

She advises physicians who are unhappy after acquisitions to speak up and stick together.

“That’s the biggest thing I think physicians should start doing,” she said. “Support each other and stand up. You are stronger together.”
 

Why is PE so attracted to health care?

PE firms typically buy practices or hospitals, work to make the entities more profitable, and then sell them, with the goal of doubling or tripling their investment over a short period. In general, PE firms aim for annual returns exceeding 20% after 3-7 years.

These firms know that health care is relatively recession-proof, that providers have third-party payers, and that the industry is fragmented and requires more efficiency, Ms. Dooley said.

When PE practice acquisitions started gaining momentum about 12 years ago, traditional hospital-based specialties such as anesthesiology and radiology were prime targets, said Mr. Strode.

At the same time, increasing challenges in private practice, such as declining compensation from payers, pressure to participate in value-based care programs, and rising regional competitors have fueled more physician groups to partner with PE firms, Mr. Herschman noted.

Physicians who partner with PE firms often benefit by having new access to capital to grow their practices, cost savings through group purchasing, and the ability to compete with larger health groups, Mr. Herschman said.

Questions remain, however, about how PE involvement affects health care use and spending. An April 2023 JAMA Viewpoint article called out the lack of oversight and regulation in the health care/PE space, suggesting that a stronger framework for regulation and transparency is needed.

A 2022 study in JAMA Health Forum that examined changes in prices and utilization associated with the PE acquisitions of 578 dermatology, gastroenterology, and ophthalmology physician practices from 2016 to 2020 found that prices increased by an average of 11%, and volume rose by 16%, after acquisition.

“We found that acquisitions were associated with increases in health care spending and utilization, as well as some other patterns of care like potential upcoding,” said Jane M. Zhu, MD, an author of the study and assistant professor at Oregon Health & Science University in Portland.

Another recent study that Dr. Zhu coauthored, published in Health Affairs, found that physician practices acquired by PE firms experience greater staff turnover and rely more heavily on advanced practice professionals than doctors.

“To the extent that that turnover indicates physicians are dissatisfied after private equity comes in, that’s really important to investigate further,” Dr. Zhu said.

PE firms owned 4% of U.S. hospitals in 2021 and 11% of nursing homes, according to a Medicare Payment Advisory Commission (MedPAC) report. The report does not include 2021 data on medical practices but notes that from 2013 to 2016, PE firms acquired at least 2% of physician practices. Estimates of PE deals are probably lower than actual numbers because of the lack of comprehensive information sources, according to the MedPAC report.

A version of this article appeared on Medscape.com.

Key clinical point: Despite improvements in COVID-19 clinical outcomes in the SARS-CoV-2 Omicron era, patients with rheumatoid arthritis (RA) remain at higher risk for COVID-19-associated adverse outcomes compared with the general population, suggesting continued need to follow all prophylactic measures, including receiving vaccinations and antivirals against SARS-CoV-2.

Major finding: Patients with RA vs general population who contracted COVID-19 continue to be at a higher risk for COVID-19-associated hospitalization (adjusted odds ratio [aOR] 2.02; 95% CI 1.79-2.27) and death (aOR 1.73; 95% CI 1.36-2.20) despite better vaccination coverage (88.89% vs 84.07%) and more frequent use of SARS-CoV-2-directed oral antivirals (0.67% vs 0.23%) and monoclonal antibodies (0.10% vs 0.02%).

Study details: This retrospective, population-based study included 34,182 patients with RA matched with 170,910 comparators from the general population.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Bournia VK et al. Outcomes of COVID-19 Omicron variant in patients with rheumatoid arthritis: A nationwide Greek cohort study. Rheumatology (Oxford). 2023 (Jul 19). doi: 10.1093/rheumatology/kead354

Key clinical point: Despite improvements in COVID-19 clinical outcomes in the SARS-CoV-2 Omicron era, patients with rheumatoid arthritis (RA) remain at higher risk for COVID-19-associated adverse outcomes compared with the general population, suggesting continued need to follow all prophylactic measures, including receiving vaccinations and antivirals against SARS-CoV-2.

Major finding: Patients with RA vs general population who contracted COVID-19 continue to be at a higher risk for COVID-19-associated hospitalization (adjusted odds ratio [aOR] 2.02; 95% CI 1.79-2.27) and death (aOR 1.73; 95% CI 1.36-2.20) despite better vaccination coverage (88.89% vs 84.07%) and more frequent use of SARS-CoV-2-directed oral antivirals (0.67% vs 0.23%) and monoclonal antibodies (0.10% vs 0.02%).

Study details: This retrospective, population-based study included 34,182 patients with RA matched with 170,910 comparators from the general population.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Bournia VK et al. Outcomes of COVID-19 Omicron variant in patients with rheumatoid arthritis: A nationwide Greek cohort study. Rheumatology (Oxford). 2023 (Jul 19). doi: 10.1093/rheumatology/kead354

Key clinical point: Despite improvements in COVID-19 clinical outcomes in the SARS-CoV-2 Omicron era, patients with rheumatoid arthritis (RA) remain at higher risk for COVID-19-associated adverse outcomes compared with the general population, suggesting continued need to follow all prophylactic measures, including receiving vaccinations and antivirals against SARS-CoV-2.

Major finding: Patients with RA vs general population who contracted COVID-19 continue to be at a higher risk for COVID-19-associated hospitalization (adjusted odds ratio [aOR] 2.02; 95% CI 1.79-2.27) and death (aOR 1.73; 95% CI 1.36-2.20) despite better vaccination coverage (88.89% vs 84.07%) and more frequent use of SARS-CoV-2-directed oral antivirals (0.67% vs 0.23%) and monoclonal antibodies (0.10% vs 0.02%).

Study details: This retrospective, population-based study included 34,182 patients with RA matched with 170,910 comparators from the general population.

Disclosures: This study did not receive any specific funding. The authors declared no conflicts of interest.

Source: Bournia VK et al. Outcomes of COVID-19 Omicron variant in patients with rheumatoid arthritis: A nationwide Greek cohort study. Rheumatology (Oxford). 2023 (Jul 19). doi: 10.1093/rheumatology/kead354

Key clinical point: Standardized 3-dimensional computed tomography (3D-CT) showed significant loss of lung volume (LV) at acute exacerbation of rheumatoid arthritis-associated interstitial lung disease (RA-ILD), which was associated with a significant increase in the risk for mortality.

Major finding: Patients with lower vs higher 3D-CT LV had shorter survival (median 2.8 vs 41.7 months; P < .001), with standardized 3D-CT LV being significantly associated with mortality at acute exacerbation of RA-ILD (hazard ratio 0.958; P < .001). Loss of LV was predominantly in the lower lobes at diagnosis and extended to the upper and lower lobes at acute exacerbation (P < .001).

Study details: The data come from a retrospective, observational study including 54 patients with a diagnosis of RA-ILD, 53 patients admitted with an acute exacerbation of RA-ILD, and 35 control individuals.

Disclosures: This study was supported by the Japan Society for the Promotion of Science. The authors declared no conflicts of interest.

Source: Tanaka Y et al. Standardised 3D-CT lung volumes for patients with acute exacerbation of rheumatoid arthritis-associated interstitial lung disease. Rheumatology (Oxford). 2023 (Jul 17). doi: 10.1093/rheumatology/kead363

Key clinical point: Standardized 3-dimensional computed tomography (3D-CT) showed significant loss of lung volume (LV) at acute exacerbation of rheumatoid arthritis-associated interstitial lung disease (RA-ILD), which was associated with a significant increase in the risk for mortality.

Major finding: Patients with lower vs higher 3D-CT LV had shorter survival (median 2.8 vs 41.7 months; P < .001), with standardized 3D-CT LV being significantly associated with mortality at acute exacerbation of RA-ILD (hazard ratio 0.958; P < .001). Loss of LV was predominantly in the lower lobes at diagnosis and extended to the upper and lower lobes at acute exacerbation (P < .001).

Study details: The data come from a retrospective, observational study including 54 patients with a diagnosis of RA-ILD, 53 patients admitted with an acute exacerbation of RA-ILD, and 35 control individuals.

Disclosures: This study was supported by the Japan Society for the Promotion of Science. The authors declared no conflicts of interest.

Source: Tanaka Y et al. Standardised 3D-CT lung volumes for patients with acute exacerbation of rheumatoid arthritis-associated interstitial lung disease. Rheumatology (Oxford). 2023 (Jul 17). doi: 10.1093/rheumatology/kead363

Key clinical point: Standardized 3-dimensional computed tomography (3D-CT) showed significant loss of lung volume (LV) at acute exacerbation of rheumatoid arthritis-associated interstitial lung disease (RA-ILD), which was associated with a significant increase in the risk for mortality.

Major finding: Patients with lower vs higher 3D-CT LV had shorter survival (median 2.8 vs 41.7 months; P < .001), with standardized 3D-CT LV being significantly associated with mortality at acute exacerbation of RA-ILD (hazard ratio 0.958; P < .001). Loss of LV was predominantly in the lower lobes at diagnosis and extended to the upper and lower lobes at acute exacerbation (P < .001).

Study details: The data come from a retrospective, observational study including 54 patients with a diagnosis of RA-ILD, 53 patients admitted with an acute exacerbation of RA-ILD, and 35 control individuals.

Disclosures: This study was supported by the Japan Society for the Promotion of Science. The authors declared no conflicts of interest.

Source: Tanaka Y et al. Standardised 3D-CT lung volumes for patients with acute exacerbation of rheumatoid arthritis-associated interstitial lung disease. Rheumatology (Oxford). 2023 (Jul 17). doi: 10.1093/rheumatology/kead363

Key clinical point: Opioids not only increase the risk for all-cause mortality among patients with rheumatoid arthritis (RA) but also carry a similar risk for major adverse cardiovascular events (MACE) as nonsteroidal anti-inflammatory drugs (NSAID).

Major finding: The risk for MACE was similar among patients initiating opioids and those initiating NSAID (adjusted hazard ratio [aHR] 1.02; 95% CI 0.85-1.22); however, opioid initiators had a 33% higher risk for all-cause mortality compared with NSAID initiators (aHR 1.33; 95% CI 1.06-1.67).

Study details: This new user active comparator cohort study included patients with RA within the FORWARD databank and propensity-score matched patients initiating opioids (n = 6866) to those initiating NSAID (n = 13,689).

Disclosures: This study was supported by the Rheumatology Research Foundation Resident Preceptor Award. The authors declared no conflicts of interest.

Source: Ozen G et al. Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis. Ann Rheum Dis. 2023 (Jul 17). doi: 10.1136/ard-2023-224339

Key clinical point: Opioids not only increase the risk for all-cause mortality among patients with rheumatoid arthritis (RA) but also carry a similar risk for major adverse cardiovascular events (MACE) as nonsteroidal anti-inflammatory drugs (NSAID).

Major finding: The risk for MACE was similar among patients initiating opioids and those initiating NSAID (adjusted hazard ratio [aHR] 1.02; 95% CI 0.85-1.22); however, opioid initiators had a 33% higher risk for all-cause mortality compared with NSAID initiators (aHR 1.33; 95% CI 1.06-1.67).

Study details: This new user active comparator cohort study included patients with RA within the FORWARD databank and propensity-score matched patients initiating opioids (n = 6866) to those initiating NSAID (n = 13,689).

Disclosures: This study was supported by the Rheumatology Research Foundation Resident Preceptor Award. The authors declared no conflicts of interest.

Source: Ozen G et al. Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis. Ann Rheum Dis. 2023 (Jul 17). doi: 10.1136/ard-2023-224339

Key clinical point: Opioids not only increase the risk for all-cause mortality among patients with rheumatoid arthritis (RA) but also carry a similar risk for major adverse cardiovascular events (MACE) as nonsteroidal anti-inflammatory drugs (NSAID).

Major finding: The risk for MACE was similar among patients initiating opioids and those initiating NSAID (adjusted hazard ratio [aHR] 1.02; 95% CI 0.85-1.22); however, opioid initiators had a 33% higher risk for all-cause mortality compared with NSAID initiators (aHR 1.33; 95% CI 1.06-1.67).

Study details: This new user active comparator cohort study included patients with RA within the FORWARD databank and propensity-score matched patients initiating opioids (n = 6866) to those initiating NSAID (n = 13,689).

Disclosures: This study was supported by the Rheumatology Research Foundation Resident Preceptor Award. The authors declared no conflicts of interest.

Source: Ozen G et al. Major adverse cardiovascular events and mortality with opioids versus NSAIDs initiation in patients with rheumatoid arthritis. Ann Rheum Dis. 2023 (Jul 17). doi: 10.1136/ard-2023-224339

Key clinical point: The use of combination therapy or biologics was associated with a lower risk for diabetes than methotrexate monotherapy in patients with rheumatoid arthritis (RA), with hydroxychloroquine having a significant protective effect on the development of diabetes.

Major finding: The risk for diabetes was significantly lower in the biologic disease-modifying antirheumatic drug (DMARD) periods (adjusted hazard ratio [aHR] 0.51; 95% CI 0.32-0.83), methotrexate combination periods (aHR 0.50; 95% CI 0.32-0.78), and other conventional DMARD periods (aHR 0.56; 95% CI 0.37-0.84) than in the methotrexate monotherapy periods. Hydroxychloroquine (aHR 0.52; P < .001) and sulfasalazine (aHR 0.69; P  =  .002) had a significant protective effect on diabetes development.

Study details: The data come from a retrospective cohort study that included 5530 adults with RA without diabetes.

Disclosures: This study did not declare any specific funding or conflicts of interest.

Source: Su YJ et al. Disease-modifying anti-rheumatic drugs associated with different diabetes risks in patients with rheumatoid arthritis. RMD Open. 2023;9:e003045 (Jul 17). doi: 10.1136/rmdopen-2023-003045

Key clinical point: The use of combination therapy or biologics was associated with a lower risk for diabetes than methotrexate monotherapy in patients with rheumatoid arthritis (RA), with hydroxychloroquine having a significant protective effect on the development of diabetes.

Major finding: The risk for diabetes was significantly lower in the biologic disease-modifying antirheumatic drug (DMARD) periods (adjusted hazard ratio [aHR] 0.51; 95% CI 0.32-0.83), methotrexate combination periods (aHR 0.50; 95% CI 0.32-0.78), and other conventional DMARD periods (aHR 0.56; 95% CI 0.37-0.84) than in the methotrexate monotherapy periods. Hydroxychloroquine (aHR 0.52; P < .001) and sulfasalazine (aHR 0.69; P  =  .002) had a significant protective effect on diabetes development.

Study details: The data come from a retrospective cohort study that included 5530 adults with RA without diabetes.

Disclosures: This study did not declare any specific funding or conflicts of interest.

Source: Su YJ et al. Disease-modifying anti-rheumatic drugs associated with different diabetes risks in patients with rheumatoid arthritis. RMD Open. 2023;9:e003045 (Jul 17). doi: 10.1136/rmdopen-2023-003045

Key clinical point: The use of combination therapy or biologics was associated with a lower risk for diabetes than methotrexate monotherapy in patients with rheumatoid arthritis (RA), with hydroxychloroquine having a significant protective effect on the development of diabetes.

Major finding: The risk for diabetes was significantly lower in the biologic disease-modifying antirheumatic drug (DMARD) periods (adjusted hazard ratio [aHR] 0.51; 95% CI 0.32-0.83), methotrexate combination periods (aHR 0.50; 95% CI 0.32-0.78), and other conventional DMARD periods (aHR 0.56; 95% CI 0.37-0.84) than in the methotrexate monotherapy periods. Hydroxychloroquine (aHR 0.52; P < .001) and sulfasalazine (aHR 0.69; P  =  .002) had a significant protective effect on diabetes development.

Study details: The data come from a retrospective cohort study that included 5530 adults with RA without diabetes.

Disclosures: This study did not declare any specific funding or conflicts of interest.

Source: Su YJ et al. Disease-modifying anti-rheumatic drugs associated with different diabetes risks in patients with rheumatoid arthritis. RMD Open. 2023;9:e003045 (Jul 17). doi: 10.1136/rmdopen-2023-003045

Key clinical point: Cleaning activities and dusty clothes laundry are underestimated yet potential sources of lifetime silicon dioxide (SiO₂) exposure in women with rheumatoid arthritis (RA); high SiO₂ exposure increases the risk for mediastinal lymphadenopathy.

Major finding: Cleaning activities were the major source of SiO₂ exposure in women with RA and control individuals, with the exposure scores for occupational and non-occupational cleaning activities and occupational dusty work clothes laundry (all P < .05) being higher in women with RA vs control individuals and high SiO₂ exposure was associated with a greater risk for mediastinal lymphadenopathy (adjusted odds ratio 6.3; 95% CI 1.4-27.7).

Study details: This retrospective, case-control study obtained lifetime SiO₂ exposure data from the Dust Exposure Life-Course Questionnaire administered to 97 patients with RA, including 76 women who were matched with 308 control individuals from the general population.

Disclosures: The SILICOSIS Project was sponsored by the European Research Council. The authors declared no conflicts of interest.

Source: Sigaux J et al. Are cleaning activities a source of exposure to crystalline silica in women with rheumatoid arthritis? A case-control study. RMD Open. 2023;9:e003205 (Aug 2). doi: 10.1136/rmdopen-2023-003205

Key clinical point: Cleaning activities and dusty clothes laundry are underestimated yet potential sources of lifetime silicon dioxide (SiO₂) exposure in women with rheumatoid arthritis (RA); high SiO₂ exposure increases the risk for mediastinal lymphadenopathy.

Major finding: Cleaning activities were the major source of SiO₂ exposure in women with RA and control individuals, with the exposure scores for occupational and non-occupational cleaning activities and occupational dusty work clothes laundry (all P < .05) being higher in women with RA vs control individuals and high SiO₂ exposure was associated with a greater risk for mediastinal lymphadenopathy (adjusted odds ratio 6.3; 95% CI 1.4-27.7).

Study details: This retrospective, case-control study obtained lifetime SiO₂ exposure data from the Dust Exposure Life-Course Questionnaire administered to 97 patients with RA, including 76 women who were matched with 308 control individuals from the general population.

Disclosures: The SILICOSIS Project was sponsored by the European Research Council. The authors declared no conflicts of interest.

Source: Sigaux J et al. Are cleaning activities a source of exposure to crystalline silica in women with rheumatoid arthritis? A case-control study. RMD Open. 2023;9:e003205 (Aug 2). doi: 10.1136/rmdopen-2023-003205

Key clinical point: Cleaning activities and dusty clothes laundry are underestimated yet potential sources of lifetime silicon dioxide (SiO₂) exposure in women with rheumatoid arthritis (RA); high SiO₂ exposure increases the risk for mediastinal lymphadenopathy.

Major finding: Cleaning activities were the major source of SiO₂ exposure in women with RA and control individuals, with the exposure scores for occupational and non-occupational cleaning activities and occupational dusty work clothes laundry (all P < .05) being higher in women with RA vs control individuals and high SiO₂ exposure was associated with a greater risk for mediastinal lymphadenopathy (adjusted odds ratio 6.3; 95% CI 1.4-27.7).

Study details: This retrospective, case-control study obtained lifetime SiO₂ exposure data from the Dust Exposure Life-Course Questionnaire administered to 97 patients with RA, including 76 women who were matched with 308 control individuals from the general population.

Disclosures: The SILICOSIS Project was sponsored by the European Research Council. The authors declared no conflicts of interest.

Source: Sigaux J et al. Are cleaning activities a source of exposure to crystalline silica in women with rheumatoid arthritis? A case-control study. RMD Open. 2023;9:e003205 (Aug 2). doi: 10.1136/rmdopen-2023-003205

Key clinical point: Abatacept showed similar efficacy and safety in patients with rheumatoid arthritis (RA) with vs without previous malignancies and did not increase the risk for malignancy or relapse.

Major finding: Patients with RA with and without previous malignancies had no significant differences in the disease activity scores for 28 Joints based on C-reactive protein (up to 60 months after initiating abatacept; P  =  .36), 10-year abatacept continuation rates (P  =  .70), and the incidence rates of malignancies after initiating abatacept (adjusted hazard ratio 0.99; P  =  1.00).

Study details: This retrospective study included 312 patients with RA who received abatacept, of whom 23.4% patients had previous malignancies when initiating abatacept.

Disclosures: This study was partly supported by JSPS KAKENHI and the Japan Rheumatism Foundation. Y Kunishita declared receiving personal fees from Bristol-Myers K.K. and Eisai, which are unrelated to this study. The other authors did not report any conflicts of interest.

Source: Kunishita Y et al. Efficacy and safety of abatacept in patients with rheumatoid arthritis with previous malignancy. Ther Adv Musculoskelet Dis. 2023;15 (Aug 1). doi: 10.1177/1759720X231186874

Key clinical point: Abatacept showed similar efficacy and safety in patients with rheumatoid arthritis (RA) with vs without previous malignancies and did not increase the risk for malignancy or relapse.

Major finding: Patients with RA with and without previous malignancies had no significant differences in the disease activity scores for 28 Joints based on C-reactive protein (up to 60 months after initiating abatacept; P  =  .36), 10-year abatacept continuation rates (P  =  .70), and the incidence rates of malignancies after initiating abatacept (adjusted hazard ratio 0.99; P  =  1.00).

Study details: This retrospective study included 312 patients with RA who received abatacept, of whom 23.4% patients had previous malignancies when initiating abatacept.

Disclosures: This study was partly supported by JSPS KAKENHI and the Japan Rheumatism Foundation. Y Kunishita declared receiving personal fees from Bristol-Myers K.K. and Eisai, which are unrelated to this study. The other authors did not report any conflicts of interest.

Source: Kunishita Y et al. Efficacy and safety of abatacept in patients with rheumatoid arthritis with previous malignancy. Ther Adv Musculoskelet Dis. 2023;15 (Aug 1). doi: 10.1177/1759720X231186874

Key clinical point: Abatacept showed similar efficacy and safety in patients with rheumatoid arthritis (RA) with vs without previous malignancies and did not increase the risk for malignancy or relapse.

Major finding: Patients with RA with and without previous malignancies had no significant differences in the disease activity scores for 28 Joints based on C-reactive protein (up to 60 months after initiating abatacept; P  =  .36), 10-year abatacept continuation rates (P  =  .70), and the incidence rates of malignancies after initiating abatacept (adjusted hazard ratio 0.99; P  =  1.00).

Study details: This retrospective study included 312 patients with RA who received abatacept, of whom 23.4% patients had previous malignancies when initiating abatacept.

Disclosures: This study was partly supported by JSPS KAKENHI and the Japan Rheumatism Foundation. Y Kunishita declared receiving personal fees from Bristol-Myers K.K. and Eisai, which are unrelated to this study. The other authors did not report any conflicts of interest.

Source: Kunishita Y et al. Efficacy and safety of abatacept in patients with rheumatoid arthritis with previous malignancy. Ther Adv Musculoskelet Dis. 2023;15 (Aug 1). doi: 10.1177/1759720X231186874

Key clinical point: The tapering of low-dose prednisolone over a 3-month schedule led to a moderate increase in disease activity to the levels of the placebo group, suggesting the feasibility of withdrawal of low-dose prednisolone in elderly patients with rheumatoid arthritis (RA) after successful completion of 2 years of therapy.

Major finding: After 3 months of tapering, increase in the Disease Activity Score for 28 Joints was moderate and not significantly different for the prednisolone and placebo groups (between-group difference 0.16; P  =  .12), with flares being only numerically higher in the prednisolone vs placebo group (45% vs 33%; P  =  .12).

Study details: This observational controlled cohort study included 191 patients with RA age ≥ 65 years from the GLORIA trial who underwent linear tapering of 5 mg/day prednisolone or placebo after 2 years of administration, to zero over a period of 3 months.

Disclosures: This study was funded by the European Union’s Horizon 2020 research and innovation program. Several authors declared ties with various sources.

Source: Almayali AAH et al. Three-month tapering and discontinuation of long-term, low-dose glucocorticoids in senior patients with rheumatoid arthritis is feasible and safe: Placebo-controlled double blind tapering after the GLORIA trial. Ann Rheum Dis. 2023 (Aug 4). doi: 10.1136/ard-2023-223977

Key clinical point: The tapering of low-dose prednisolone over a 3-month schedule led to a moderate increase in disease activity to the levels of the placebo group, suggesting the feasibility of withdrawal of low-dose prednisolone in elderly patients with rheumatoid arthritis (RA) after successful completion of 2 years of therapy.

Major finding: After 3 months of tapering, increase in the Disease Activity Score for 28 Joints was moderate and not significantly different for the prednisolone and placebo groups (between-group difference 0.16; P  =  .12), with flares being only numerically higher in the prednisolone vs placebo group (45% vs 33%; P  =  .12).

Study details: This observational controlled cohort study included 191 patients with RA age ≥ 65 years from the GLORIA trial who underwent linear tapering of 5 mg/day prednisolone or placebo after 2 years of administration, to zero over a period of 3 months.

Disclosures: This study was funded by the European Union’s Horizon 2020 research and innovation program. Several authors declared ties with various sources.

Source: Almayali AAH et al. Three-month tapering and discontinuation of long-term, low-dose glucocorticoids in senior patients with rheumatoid arthritis is feasible and safe: Placebo-controlled double blind tapering after the GLORIA trial. Ann Rheum Dis. 2023 (Aug 4). doi: 10.1136/ard-2023-223977

Key clinical point: The tapering of low-dose prednisolone over a 3-month schedule led to a moderate increase in disease activity to the levels of the placebo group, suggesting the feasibility of withdrawal of low-dose prednisolone in elderly patients with rheumatoid arthritis (RA) after successful completion of 2 years of therapy.

Major finding: After 3 months of tapering, increase in the Disease Activity Score for 28 Joints was moderate and not significantly different for the prednisolone and placebo groups (between-group difference 0.16; P  =  .12), with flares being only numerically higher in the prednisolone vs placebo group (45% vs 33%; P  =  .12).

Study details: This observational controlled cohort study included 191 patients with RA age ≥ 65 years from the GLORIA trial who underwent linear tapering of 5 mg/day prednisolone or placebo after 2 years of administration, to zero over a period of 3 months.

Disclosures: This study was funded by the European Union’s Horizon 2020 research and innovation program. Several authors declared ties with various sources.

Source: Almayali AAH et al. Three-month tapering and discontinuation of long-term, low-dose glucocorticoids in senior patients with rheumatoid arthritis is feasible and safe: Placebo-controlled double blind tapering after the GLORIA trial. Ann Rheum Dis. 2023 (Aug 4). doi: 10.1136/ard-2023-223977