Jing Li’s research while affiliated with San Francisco VA Medical Center and other places

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Publications (43)


Drivers of infliximab biosimilar uptake: A comparative analysis of new biosimilar initiations versus switching in a national rheumatology registry
  • Article

December 2024

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8 Reads

Health Services Research

Eric Thomas Roberts

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Nick Bansback

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Chien-Wen Tseng

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Objective To analyze the variability in new infliximab biosimilar starts as well as switching from bio‐originator to biosimilar infliximab, across insurance payers and rheumatology practices nationally. Study Setting and Design Data came from Rheumatology Informatics System for Effectiveness, a national registry with electronic health records from over 1100 US rheumatologists. Key outcomes include ever use of a biosimilar, date of initiation, and date of switching. Key variables of interest include insurance payer and practice. Data Sources and Analytic Sample Secondary analysis of 37,560 patients aged ≥18 years administered infliximab (bio‐originator or biosimilar) between April 2016 and September 2022 in Rheumatology Informatics System for Effectiveness. We tested for differences in use of biosimilar infliximab by demographic characteristics, socioeconomic status, and diagnosis using standard mean differences and multivariable modified Poisson regression. We used generalized estimating equations to assess the adjusted effect of insurance and year of initiation on new biosimilar starts. We analyzed variation in biosimilar switching by insurance, date of switch, and practice. Principal Findings A total of 8196 (21.8%) infliximab users ever used a biosimilar and use did not differ significantly by demographic or clinical characteristics. In 2022, uptake among new users was higher among those with Medicaid (55%; 95%CI 43%–68%) and private insurance (51%; 95%CI 46%–57%) compared to Medicare (36%; 95%CI 29%–43%). Few prevalent bio‐originator infliximab users switched to a biosimilar, and switching was lowest among Medicare beneficiaries (7% vs. 14.2% in Medicaid and 16.9% among privately insured). In adjusted analyses, practice level differences explained 37% of variation among new biosimilar starts and 34% of variation among those switching to a biosimilar. Conclusions Our findings underscore two critical areas for enhancing biosimilar infliximab usage: increasing switching among prevalent users and increasing uptake among Medicare beneficiaries initiating treatment. Significant variation in uptake across practices also suggests that local switching policies are likely key drivers of uptake.


Primary outcome for the longitudinal analysis: predicted proportion of a decline in Multidimensional Health Assessment Questionnaire score of >1.2 by sex and ADI quintiles. ADI, Area Deprivation Index; SES, socioeconomic status.
Low Socioeconomic Status and Female Sex are Associated With Worse Functional Status in Axial Spondyloarthritis
  • Article
  • Publisher preview available

October 2024

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11 Reads

Objective We determined whether socioeconomic status (SES) and sex are associated with functional status (FS) in axial spondyloarthritis (axSpA). Methods We conducted a cohort study of patients with axSpA in the Rheumatology Informatics System for Effectiveness registry. We performed cross‐sectional and longitudinal analyses of FS through the Multidimensional Health Assessment Questionnaire (MDHAQ) using generalized estimating equation models. Area Deprivation Index (ADI) was used as an SES proxy. The cross‐sectional analysis tested for a linear trend across ADI quintiles for MDHAQ. The longitudinal analysis’ outcome was functional decline. We reported predictive margins and assessed for interaction with sex. In the longitudinal analysis, we reported odds of functional decline. Results In the cross‐sectional analysis (N = 5,658), the mean ± SD age was 53.8 ± 15.2 years, 55.8% were female, and 71.4% were non‐Hispanic White. The mean ± SD MDHAQ scores were 1.6 ± 2.0 in men versus 2.1 ± 2.2 in women. Predicted mean MDHAQ scores were 2.2 (95% confidence interval [CI] 1.8–2.7) for the lowest ADI quintile and 1.8 (95% CI 1.4–2.1) for the highest. Women had lower FSs compared to men across quintiles. In the longitudinal analysis (n = 2,341), the proportion with FS decline was 14.3% (95% CI 7.6–25.5%) for the lowest SES quintile compared to 9.6% (95% CI 5.2–17.1%) for the highest. Women had 1.7 (95% CI 1.3–2.2) times higher odds of functional decline compared to men. There was no interaction with sex. Conclusion In this large sample of patients with axSpA, those with lower SES had worse FS and functional decline. Women had worse FS than men, initially and over time.

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Screenshot of the RA PRO dashboard. Nasrallah C, Wilson C, Hamblin A, Young C, Jacobsohn L, Nakamura MC, Gross A, Matloubian M, Ashouri J, Yazdany J, Schmajuk G. Using the technology acceptance model to assess clinician perceptions and experiences with a rheumatoid arthritis outcomes dashboard: qualitative study. BMC Med Inform Decis Mak. 2024 May 27;24(1):140. https://doi.org/10.1186/s12911-024-02530-2. PMID: 38802865; PMCID: PMC11129391
Generated themes and sub-themes as the ecological model
Table 3 (continued)
Benefits and limitations of collecting RA outcome measures and using the RA PRO dashboard as per the Ecological Model of Health-Interview quotes
Patient perceptions of an electronic-health-record-based rheumatoid arthritis outcomes dashboard: a mixed-methods study

October 2024

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3 Reads

BMC Medical Informatics and Decision Making

Background Outcome measures are crucial to support a treat-to-target approach to rheumatoid arthritis (RA) care, yet their integration into clinical practice remains inconsistent. We developed an Electronic Heath Record-integrated, patient-facing side-car application to display RA outcomes (disease activity, functional status, pain scores), medications, and lab results during clinical visits (“RA PRO Dashboard”). The study aimed to evaluate patient perceptions and attitudes towards the implementation of a novel patient-facing dashboard during clinical visits using a mixed-methods approach. Methods RA patients whose clinicians used the dashboard at least once during their clinical visit were invited to complete a survey regarding its usefulness in care. We also conducted semi-structured interviews with a subset of patients to assess their perceptions of the dashboard. The interviews were transcribed verbatim and analyzed thematically using deductive and inductive techniques. Emerging themes and subthemes were organized into four domains of the Ecological Model of Health. Results Out of 173 survey respondents, 79% were interested in seeing the dashboard again at a future visit, 71% felt it improved their understanding of their disease, and 65% believed it helped with decision-making about their RA care. Many patients reported that the dashboard helped them discuss their RA symptoms (76%) and medications (72%) with their clinician. Interviews with 29 RA patients revealed 10 key themes: the dashboard was perceived as a valuable visual tool that improved patients’ understanding of RA outcome measures, enhanced their involvement in care, and increased their trust in clinicians and the clinic. Common reported limitations included concerns about reliability of RA outcome questionnaires for some RA patients and inconsistent collection and explanation of these measures by clinicians. Conclusions In both the quantitative and qualitative components of the study, patients reported that the dashboard improved their understanding of their RA, enhanced patient-clinician communication, supported shared decision-making, and increased patient engagement in care. These findings support the use of dashboards or similar data visualization tools in RA care and can be used in future interventions to address challenges in data collection and patient education.



A step-by-step roadmap for the development and deployment of an electronic health record sidecar application that tracks patient outcomes: The RA PRO dashboard

October 2024

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11 Reads

Objective Despite interest in optimizing the electronic health record (EHR) to facilitate chronic disease care for conditions like rheumatoid arthritis (RA), progress in this area has been slow. EHR sidecar applications offer one solution, but little guidance exists to facilitate their successful development, deployment, and maintenance in the healthcare setting. We aimed to provide a roadmap for how to develop and deploy an EHR sidecar application based on our experience building a new EHR-integrated, patient-facing visualization tool that displayed disease outcomes to RA patients during a clinical visit (the “RA PRO dashboard”) in a large academic health center. Methods We describe the technical design and implementation of the RA PRO dashboard; report clinic workflow adaptations to incorporate this new technology; and discuss the resources required and challenges encountered in maintaining this application. Results The RA PRO dashboard required extensive human-centered design work, regulatory approvals, software development, user testing, integration with Epic-based workflows, and maintenance. Key requirements were prioritized based on the anticipated effects on usefulness and ease of use. Implementation science strategies were used to improve use of the dashboard in clinic and included education for patients, staff, and clinicians; reports of actual use of the dashboard and data quality; and regular meetings between the research team and clinicians to discuss and address barriers to use. Conclusion Successful development and deployment of an EHR-integrated application are resource-intensive and require technical, operational, and educational innovations. The roadmap presented in this study can serve as a resource for future developers.


Agreement of Medication Information Derived From EHR Data Compared to Medicare Insurance Claims: An Analysis of Biologic Disease-Modifying Antirheumatic Drugs

October 2024

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2 Reads

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1 Citation

Pharmacoepidemiology and Drug Safety

Purpose: Few studies have reported the agreement between medication information derived from ambulatory EHR data compared to administrative claims for high-cost specialty drugs. We used data from a national EHR-enabled registry, the Rheumatology Informatics System for Effectiveness (RISE), with linked Medicare claims in a population of patients with rheumatoid arthritis (RA) to investigate variations in agreement for different biologic disease-modifying agents (bDMARDs) between two data sources (RISE EHR data vs. Medicare claims), categorized by drug, route of administration, and patient insurance factors (dual eligibility). Methods: Patients ≥ 65 years old, with ≥ 2 visits in RISE with RA ICD codes ≥ 30 days apart, and continuous enrollment in Medicare Parts B and D in 2017-2018 were included. We classified patients as bDMARD users or nonusers in Medicare claims or EHR data in 2018, and we calculated sensitivity, specificity, positive predicted value (PPV), and negative predicted value (NPV) of EHR data for identifying bDMARD users, using Medicare as the reference standard. We also calculated these metrics after stratifying by clinic-administered (Part B) versus. pharmacy-dispensed (Part D) bDMARDs and by patient dual-eligibility. Results: A total of 26 097 patients were included in the study. Using Medicare claims as the reference standard, EHR data had a sensitivity of 75.0%-90.8% for identifying patients with the same medication and route. PPV for Part B bDMARDs was higher compared with Part D bDMARDs (range 94.3%-97.3% vs. 51.0%-69.6%). We observed higher PPVs for Part D bDMARDs among patients who were dual-eligible (range 82.4%-95.1%). Conclusion: The risk of misclassification of drug exposure based on EHR data sources alone is small for Medicare Part B bDMARDs but could be as high as 50% for Part D bDMARDs, in particular for patients who are not dually eligible for Medicare and Medicaid.


Figure 2 Contraceptive effectiveness among women with SLE with documented contraception, categorised by the teratogenicity of their rheumatic medications and other risk factors for contraceptive use. The red bar indicates the percentage of women using an oestrogen-containing contraception*, which includes oestrogen-progesterone pills, patch and ring. IUD, intrauterine device; LN, lupus nephritis; MMF, mycophenolate mofetil; MTX, methotrexate.
Contraception documentation based on patient characteristics in the prepandemic and mid-pandemic periods Prepandemic: 2019 Mid-pandemic: April 2020-March 2021
Alignment of contraception use with the ACR reproductive health guidelines in women with systemic lupus erythematosus within the RISE registry

August 2024

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15 Reads

Lupus Science & Medicine

Objectives Contraception is crucial for safely timing pregnancies in patients with SLE. This study investigated predictors of contraception documentation in patients with SLE, and the alignment of contraception practices with the 2020 American College of Rheumatology (ACR) guidelines, within the Rheumatology Informatics System for Effectiveness (RISE) registry. Materials and methods Female patients (aged 18–44 years) with SLE were identified via International Classification of Diseases (ICD)-9/ICD-10 coding within the RISE registry, which includes data from rheumatology clinics across the USA. Eligible patients were required to have ≥1 clinical visit in 2019 (prepandemic) or between 1 April 2020 and 30 March 2021 (mid-pandemic). Adjusted multilevel logistic modelling assessed patient, provider and practice characteristics for associations with contraception documentation. Contraception patterns were identified and compared with the 2020 ACR guidelines. Results Contraception documentation rates were similar in the prepandemic and mid-pandemic groups (8.1% and 8.5%, respectively). Higher documentation rates were found in women who were younger, White, and had more visits, as well as those seen within a health system, by a female provider, and within specific regions and electronic health record (EHR) systems. Prescription of a teratogenic medication did not influence contraception documentation or type. Oestrogen-containing contraceptives were prescribed less often to women at high risk for thrombosis (26.2% with thrombotic risk vs 60.6% without, p<0.0001) and history of lupus nephritis (LN) (53.8% with history of LN vs 63.2% without, p=0.024). Conclusions Practices participating in the RISE registry do not currently record contraception in the large majority of women with SLE, although increased documentation in some EHRs suggests that system changes may improve rates of documentation. Women at higher risk for thrombosis were less likely to receive oestrogen, suggesting that warnings against oestrogen use has impacted contraception prescription, although the limited documentation and limited contraception among women taking teratogenic medications suggest a high unmet need.



Interrupted time series analysis of the overall proportion of prescriptions dispensed that were biosimilar infliximab by insurance coverage. Each dot represents the actual proportion of prescriptions dispensed. The vertical dotted lines represent the market launch for each biosimilar infliximab product that was the modeled interruption.
Patterns of Infliximab Biosimilar Uptake for Medicare, Medicaid, and Private Insurance from 2016 to 2022

August 2024

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15 Reads

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2 Citations

Objective Biosimilars have the potential to reduce spending on biologic drugs, yet uptake has been slower than anticipated. We investigated how successive introductions of infliximab biosimilars influenced their adoption by major US insurance providers. Methods Data came from the Rheumatology Informatics System for Effectiveness, a national registry with electronic health records from more than 1,100 US rheumatologists. All infliximab administrations (bio‐originator or biosimilar) to patients aged ≥18 years from April 2016 to September 2022 were included. We used an interrupted time series to model the effect of each infliximab biosimilar release (infliximab‐dyyb, November 2016; infliximab‐adba, July 2017; and infliximab‐axxq, July 2020) on uptake across Medicare, Medicaid, and private insurers. Results With the first and second biosimilar releases, biosimilar uptake rose slowly, with average annual increases of ≤5% from 2016 to June 2020 (Medicare 3.2%, Medicaid 5.2%, and private insurance 1.8%). With the third biosimilar release in July 2020, the average annual increase reached 13% for Medicaid and 16.4% for private insurance but remained low for Medicare (5.6%). By September 2022, uptake was higher for Medicaid (43.8%) and private insurance (38.5%) than for Medicare (24%). Conclusion Our results have two key findings for policy makers. First, our results suggest that one or two biosimilars may not generate enough competition to speed adoption rates for biosimilars. Second, Medicare, which covers most patients receiving biologics nationally, had slow adoption rates even after the third biosimilar was introduced. Policy levers to speed adoption among Medicare beneficiaries are needed.


National rollout of a medication safety dashboard to improve testing for latent infections among biologic and targeted synthetic disease-modifying agent users within the Veterans Health Administration

July 2024

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10 Reads

Health Services Research

Objective To develop, deploy, and evaluate a national, electronic health record (EHR)‐based dashboard to support safe prescribing of biologic and targeted synthetic disease‐modifying agents (b/tsDMARDs) in the United States Veterans Affairs Healthcare System (VA). Data Sources and Study Setting We extracted and displayed hepatitis B (HBV), hepatitis C (HCV), and tuberculosis (TB) screening data from the EHR for users of b/tsDMARDs using PowerBI (Microsoft) and deployed the dashboard to VA facilities across the United States in 2022; we observed facilities for 44 weeks post‐deployment. Study Design We examined the association between dashboard engagement by healthcare personnel and the percentage of patients with all screenings complete (HBV, HCV, and TB) at the facility level using an interrupted time series. Based on frequency of sessions, facilities were grouped into high‐ and low/none‐engagement categories. We modeled changes in complete screening pre‐ and post‐deployment of the dashboard. Data Collection Methods All VA facilities were eligible for inclusion; excluded facilities participated in design of the dashboard or had <20 patients receiving b/tsDMARDs. Session counts from facility personnel were captured using PowerBI audit log data. Outcomes were assessed weekly based on EHR data extracted via the dashboard itself. Principal Findings Totally 117 facilities (serving a total of 41,224 Veterans prescribed b/tsDMARDs) were included. Before dashboard deployment, across all facilities, 61.5% of patients had all screenings complete, which improved to 66.3% over the course of the study period. The largest improvement (15 percentage points, 60.3%–75.3%) occurred among facilities with high engagement (post‐intervention difference in outcome between high and low/none‐engagement groups was 0.17 percentage points (pp) per week, 95% confidence interval (0.04 pp, 0.30 pp); p = 0.01). Conclusions We observed significant improvements in screening for latent infections among facilities with high engagement with the dashboard, compared with those with fewer sessions.


Citations (23)


... A partir dos critérios propostos, foram selecionados 15 artigos que abordam a temática da relação do uso prolongado de IBPs e seus possíveis efeitos adversos em idosos. Os resultados são apresentados no Quadro 1: (Hughes et al., 2018;Zhang et al., 2022); alterações na densidade mineral óssea (DMO) (Aleraij et al., 2020;Palmowski et al., 2024); aumento do risco de fraturas, incluindo fratura óssea (Zhang et al., 2022) e de quadril (Poly et al., 2019;Zhang et al., 2022); de pneumonias (Wang et al., 2019), principalmente pneumonia adquirida na comunidade (PAC) (Nguyen et al., 2020;Xun et al., 2022); de cânceres do trato digestivo (Zeng et al., 2021), especialmente câncer gástrico (Abraham et al., 2021;Segna et al., 2021;Zeng et al., 2021), câncer de pâncreas e câncer de fígado (Zeng et al., 2021); maior susceptibilidade a infeções entéricas, principalmente aquelas causadas por Enterococcus, Salmonella spp. (Kuo et al., 2021) e ...

Reference:

A RELAÇÃO DO USO PROLONGADO DE INIBIDORES DA BOMBA DE PRÓTONS NO CONTROLE DA DOENÇA DO REFLUXO GASTROESOFÁGICO EM IDOSOS: UMA REVISÃO NARRATIVA
Proton Pump Inhibitor Use and Bone Health in Patients With Rheumatic Diseases: A Cross-Sectional Study
  • Citing Article
  • April 2024

Mayo Clinic Proceedings

... [3][4][5][6][7] In general, given the body of evidence about the benefits of antimalarials prolonging life expectancy, decreasing risks of flares and damage 8 and the described safety profile of long-term use of glucocorticoids, [9][10][11] these recommendations could be considered 'good practice', and have been incorporated as a measure of quality of care in SLE by the American College of Rheumatology (ACR). 12 However, no contemporary clinical practice guidelines for SLE are issued by the ACR. ...

Development of American College of Rheumatology Quality Measures for Systemic Lupus Erythematosus: A Modified Delphi Process With Rheumatology Informatics System for Effectiveness (RISE) Registry Data Review

... We were restricted to a 3-year look back given the available claims data, but previous analyses that had access to screening at any time report gaps. 11,20 As a sensitivity analysis, we assessed screening rates among those with incident disease in our study population. Within 12 months of initiation, 79.2% of patients with incident disease (81.6% within 3 years) were screened (Supplementary Table S2), suggesting that, at a minimum, screening rates need to be increased among first-time users as directed by the quality measure. ...

Screening for Latent Infections Among Users of High-Risk Immunosuppressants: A Cross-Sectional Analysis From the Veterans Health Administration Healthcare System
  • Citing Article
  • November 2022

Journal of Patient Safety

... 13 Equally important, previous studies have not incorporated concomitant medications that could affect SUA levels. 14,15 Moreover, no studies to date have evaluated achieving T2T parameters over time on a population level in older adult patients with gout starting ULT. Research specifically focusing on the older adult population is important because the burden of gout increases with age. ...

Monitoring and Achievement of Target Serum Urate Among Gout Patients Receiving Long‐Term Urate‐Lowering Therapy in the American College of Rheumatology RISE Registry

... There could be concern that patients with poor FSs are more likely to fill out an MDHAQ at their rheumatology visit, biasing our results. However, previous analyses from RISE suggest that questionnaires are typically distributed to all patients in a clinic across rheumatic conditions and despite concern for assumed FS 36,37 ; in other words, we find that missingness is not completely at random, but major differences are related to practices and not individuals. We cannot rule out the possibility, however, that some patients may not complete questionnaires they are handed in the clinic and that differential missingness could bias the results. ...

The Relationship Between Electronic Health Record System and Performance on Quality Measures in the American College of Rheumatology’s Rheumatology Informatics System for Effectiveness (RISE) Registry: Observational Study

JMIR Medical Informatics

... 5 20 Particularly concerning is that patients using teratogenic medication or those with active disease are not necessarily more likely to receive contraceptive counselling or to use contraception, leading to further risks in case of an unplanned pregnancy. 21 Another relevant issue is disparities in access to care. Our participants mention barriers to access contraception based on a person's social security or health insurance status; this gap in access to low-or no-cost contraception for patients with rheumatic diseases has been previously documented. ...

Frequency of Contraception Documentation in Women With Systemic Lupus Erythematosus and Rheumatoid Arthritis Within the Rheumatology Informatics System for Effectiveness Registry

... La Enfermedad de Behçet (EB) es una vasculitis sistémica crónica de etiología desconocida, caracterizada principalmente por úlceras orales y genitales recidivantes, así como manifestaciones oftalmológicas, cutáneas y neurológicas (1,2). Esta patología se clasifica dentro de las enfermedades autoinmunes, y aunque su prevalencia es baja, su impacto en la calidad de vida de los pacientes es significativo (3). ...

Epidemiology and treatment of Behçet’s disease in the USA: insights from the Rheumatology Informatics System for Effectiveness (RISE) Registry with a comparison with other published cohorts from endemic regions

Arthritis Research & Therapy

... 12 Glucocorticoids might be associated with worse outcomes in individuals with COVID-19 in individuals with CTD, but some immune suppressants or DMARDs do not appear to significantly increase the risk of contracting COVID-19 or poor subsequent outcomes 13 . The ethnicity, age, and comorbidities such as hypertension or diabetes are reported to have a comparatively higher impact on the prognostic outcome of COVID-19 in autoimmune patients 4,14,15 . In our registry, patients with SLE were 54.5(20-95) years old, compatible with a lower rate of comorbidities (diabetes 3/32(9.4%) ...

Factors Associated With Hospitalization and Death After COVID‐19 Diagnosis Among Patients With Rheumatic Disease: An Analysis of Veterans Affairs Data

... We identified 24 studies evaluating demographic factors 15-38 and 18 studies reporting on socioeconomic factors 9,15,18,20,[22][23][24]26,28,30,33,35,[38][39][40][41][42][43] that were associated with differences in access, medication use, and health outcomes in people with RA ...

Socioeconomic Disparities in Functional Status in a National Sample of Patients With Rheumatoid Arthritis

JAMA Network Open

... Given that the study period spanned the onset of the COVID-19 pandemic, which had profound impacts on clinical practice and patient visit volume, we repeated the analyses above stratified by year due to possible changes in practice engagement due to the COVID-19 pandemic (2020 data only; 2021 data only). 62,63 In another sensitivity analysis, we restricted the sample to practices using NextGen, the most common EHR vendor (N ¼ 87). The analytic dataset was created with SAS Version 9.4 (SAS Institute) and analyses were performed using Stata 16 ...

Effects of the SARS-CoV-2 global pandemic on U.S. rheumatology outpatient care delivery and use of telemedicine: an analysis of data from the RISE registry

Rheumatology International