Abstract

Objective We sought to identify (1) what types of information US adults with rheumatic and musculoskeletal diseases (RMD) perceive as most important to know about their disease, and (2) what functions they would use in an RMD-specific smartphone app.

Methods Nominal groups with patients with RMD were conducted using online tools to generate a list of needed educational topics. Based on nominal group results, a survey with final educational items was administered online, along with questions about desired functions of a smartphone app for RMD and wearable use, to patients within a large community rheumatology practice–based research network and the PatientSpot registry. Chi-square tests and multivariate regression models were used to determine differences in priorities between groups of respondents with rheumatic inflammatory conditions (RICs) and osteoarthritis (OA), and possible associations.

Results At least 80% of respondents considered finding a rheumatologist, understanding tests and medications, and quickly recognizing and communicating symptoms to doctors as extremely important educational topics. The highest-ranked topic for both RIC and OA groups was “knowing when the medication is not working.” The app functions that most respondents considered useful were viewing laboratory results, recording symptoms to share with their rheumatology provider, and recording symptoms (eg, pain, fatigue) or disease flares for health tracking over time. Approximately one-third of respondents owned and regularly used a wearable activity tracker.

Conclusion People with RMD prioritized information about laboratory test results, medications, and disease and symptom monitoring, which can be used to create educational and digital tools that support patients during their disease journey.

Key Indexing Terms:

Generating information patients find useful for making choices about their health care is a core objective of patient-centered outcomes research (PCOR).1 This requires identifying and understanding patients’ educational needs to engage them as study partners and participants in PCOR to improve patient health outcomes. With support from the PCOR Institute, the CreakyJoints arthritis patient network (part of the nonprofit Global Healthy Living Foundation (GHLF) based in the United States) partnered with researchers at the University of Alabama at Birmingham to create ArthritisPower, a patient-powered research network registry for the purpose of planning, conducting, and disseminating research findings to inform healthcare decision making by patients and other stakeholders.2 The name of the registry, ArthritisPower, was changed to PatientSpot in 2023 to be inclusive of more patients with a broader group of chronic illnesses. We henceforth refer to ArthritisPower as PatientSpot in all instances throughout this manuscript.

Although people living with rheumatic conditions may feel unprepared to formulate research questions or articulate research priorities, when asked, they can readily express what they and their fellow patients need to learn or know about living with a disease. Such inquiry can simultaneously advance multiple aims, including (1) identifying educational priorities to inform dissemination of existing evidence, (2) guiding PCOR conducted within PatientSpot, (3) engaging patients in research, (4) increasing shared decision making, and (5) potentially improving health outcomes3,4 through patient education.

Prior educational needs assessments for people living with rheumatic conditions have typically asked patients to respond to topic lists prepared by health professionals.3,4 For example, the educational needs assessment tool (ENAT), which has been cross-culturally validated in multiple languages, countries, and disease states,5-12 was developed by researchers who used themes and domains suggested by a literature search to conduct semistructured interviews with patients. The findings of these interviews were used to categorize themes and develop the questions in the ENAT.4 A Delphi process that included patients as only 1 of the stakeholder groups has also been used to identify educational needs for people with rheumatic diseases.13

In contrast, we used a different approach, which was to first have people with RMD intuitively generate and express their educational needs in their own words before assessing and prioritizing those needs. This approach is based on evidence that patients translate physicians’ verbatim statements into their own words, or the gist of what the physicians said.14 Understanding, accuracy, and effectiveness of patient education could be increased if the clinician used patients’ gist terms (ie, their conversational language) in educational efforts. To develop responsive educational resources and inform PCOR, this study aimed to identify the information needs of people living with rheumatic diseases in their own terms, rather than terms initially generated by providers or other stakeholders. Specifically, this study was designed to examine what types of information adults with rheumatoid arthritis (RA), osteoarthritis (OA), and associated conditions perceive as important to know related to their disease and how they express and prioritize that information.

In addition to identifying patients’ educational needs in gist language, and in order to reduce burdensomeness on the provider, we sought to evaluate whether patients’ educational needs might be met using digital tools, such as the PatientSpot mobile app. As patient education continues to transition from paper to online resources,15 it is important to understand how education and other patient needs could be satisfied in a digital format. Accordingly, we evaluated which functions people living with rheumatic disease would use in a smartphone app for either research and/or clinical care. As the disease experience and treatment options available to people living with RA and other types of rheumatic inflammatory conditions (RICs) are different than those for OA, we hypothesized that item selections and relative ratings would differ between these groups. We hypothesized that participants with RICs would prioritize topics related to medication efficacy and laboratory test results used to monitor their condition more often than participants with OA.

METHODS

Nominal groups. The nominal group technique (NGT) is a structured process that helps a group reach consensus about the relative importance and priority of important issues or ideas related to a specific question.16 It was developed to explicitly include the perspectives of all stakeholders in a given problem space and to balance input from those stakeholders.16 The NGT can include a card-sorting procedure that has been used in corporate communications research, and was used for this study.17 Nominal group panels have also been used in medical research to generate lists of ideas, such as reasons for not reaching treatment goals in RA or why physicians do not intensify blood pressure medications.13,18 The process for this patient-centered study was structured to take advantage of the benefits associated with NGT, particularly ensuring that all participants’ voices are heard in the development of multiple perspectives on an issue.19

Email invitations for the nominal groups were sent to members of the online patient community CreakyJoints, a global digital community of people who have arthritis or other RMDs or provide care for people with these conditions, and to members of the affiliated PatientSpot registry (Advarra institutional review board [IRB] protocol no. 00026788). Individuals were eligible to participate if they were ≥ 19 years of age and had a self-reported, physician-diagnosed rheumatic condition. Individuals, who all had inflammatory arthritis or OA, then consented to participate in a facilitated nominal group discussion in which they were asked, “In your opinion, what information is most important to know for someone who must live with arthritis?” Participants logged on to a website and participated by phone to address the question in an efficient, ordered manner while viewing and confirming their responses in real time. Specifically, the facilitator asked the above question aloud to online participants and requested that each participant reflect on and write down their responses during a 5-minute silent period. This silent reflection period was designed to allow participants to formulate their answers independently before being influenced by the thoughts of others. After this period, the facilitator conducted a round-robin session, during which each participant was asked to contribute a single idea expressed as a phrase or brief sentence. As the ideas were shared, they were captured verbatim by a study assistant and displayed on screen in real time during the webinar for all participants to view, as if it were a whiteboard in an in-person focus group setting. Once no new items were generated, list items were reviewed to ensure that all participants had a shared understanding of the items. Participants then selected the 3 items of greatest importance to them on the list and these ranks were recorded. The most important item to each participant in the group was given a weight of 3, the second most important was given a weight of 2, and the third was given a weight of 1. All items were summed across the group to show the weighting of items by that group. This weighted list was presented to the group and participants were asked to share their impressions about the overall ranking. The nominal groups lasted approximately 60 minutes and participants were mailed a US $30 incentive for participating. Consecutive nominal group webinars were conducted until no new items or themes emerged.

Development of themes and survey. Authors RO and MS manually reviewed the NGT-generated topics and removed any duplicates.20 A 7-member panel of researchers, who were staff and students with a master’s degree, doctorate, or medical degree at the University of Alabama Birmingham School of Medicine and School of Public Health, performed a card-sorting exercise, grouping each topic into themes in a consensus-based process. Specifically, each panel member independently grouped items into their own categories. The panel then met in person to discuss their categorizations, reach agreement on the final themes, and arrange topics into those chosen themes.

To balance representation of each major theme in both depth and breadth, topics generated by the nominal groups were ordered within each theme. Topics that received ≤ 5% of the available votes within a nominal group were eliminated to arrive at a manageable number of topics (20-30 items) for survey development. Themes for the remaining topics were then ranked in order of importance by aggregating the votes within a theme across all groups, then dividing that by the total number of votes for all topics across all themes. Topics were also ranked by the number of votes received. This approach created ordered topics within each theme to facilitate the selection of educational topics to generate survey questions. During survey programming, topic wording was refined to present all topics in simple language that respondents would be more likely to understand, compared with the verbatim topics generated with NGT. Some topics were split or combined for ease of survey administration and data analysis. The final survey asked, “How important is this to you?” for each of the refined educational topics, with response options of extremely, somewhat, a little, not very, or not important. Additionally, the survey asked about 13 potential app features that were already part of the PatientSpot app or were being considered for future development and implementation, as suggested by patient advocates and clinicians. These features were informed by relevant literature on the topic,21-23 including studies of features that patients want to track in an app that would make clinic visits more efficient. We then asked our patient governors, a diverse group of 10 people living with RMD, to contribute features they would like to see in an app. After duplicates were removed, the final list comprised 13 potential app features. Finally, respondents were asked if they currently own and use a smartwatch or activity tracker, such as an Apple Watch, Fitbit, or Garmin (eg, to track sleep and activity), or intend to get one. Demographic questions, such as age, sex, ethnicity, race, time since diagnosis, and primary diagnosis, were included at the start of the survey.

Survey administration. Members of the PatientSpot registry and CreakyJoints community, as well as patients treated by providers in the Excellence Network in Rheumatology (ENRGY)—a practice-based research network of more than 300 US rheumatology providers instantiated in 2022 by Illumination Health (https://illumination.health/physician-network/)—were invited to participate in the survey.

ENRGY patients and PatientSpot/CreakyJoints members were eligible for the survey if they were aged ≥ 19 years with a diagnosis of RMD, including ankylosing spondylitis (AS), axial spondyloarthritis (axSpA), fibromyalgia (FM), gout, juvenile idiopathic arthritis (JIA), systemic lupus erythematosus (SLE), myositis, OA, osteoporosis, polymyalgia rheumatica, psoriatic arthritis (PsA), RA, Sjögren syndrome (SS), or vasculitis. For patients in the ENRGY network, these diagnoses were confirmed by International Classification of Diseases, 10th revision (ICD-10) codes in their electronic health records, whereas PatientSpot and CreakyJoints members had self-reported a diagnosis by a physician. Email invitations with a survey link were sent between January 2022 and June 2022. Unique links were used to prevent duplicate entries by the same participant. Follow-up reminder emails were sent to members who did not click on the initial invitation.

PatientSpot and CreakyJoints respondents were asked to consider all their health conditions and select 1 that they considered their primary or main health condition. The primary condition of respondents from ENRGY was verified by ICD-10 codes in electronic health record data. If the respondent had ≥ 1 health condition, their primary condition was uniquely assigned by a condition hierarchy used in prior studies and predicated on the idea that (1) more specific conditions are ranked higher and (2) more symptomatic conditions are ranked higher24-27: PsA > (AS or axSpA) > RA > JIA > SLE > SS > gout > myositis > vasculitis > polymyalgia rheumatica > FM > OA > osteoporosis. The survey was administered online using Qualtrics software.

Informed consent. All subjects provided informed consent to participate in the study. All nominal groups and surveys were conducted in English only. Human Subjects Protection oversight was provided by the University of Alabama at Birmingham IRB for the NGT and by Advarra IRB for the survey (no. Pro00060263).

Statistical analysis. Categorical variables were analyzed by frequency counts and percentages; continuous variables were analyzed by mean (SD), minimum, and maximum. Chi-square tests (statistical significance: P < 0.05) between groups of patients with RICs and OA were performed to explore differences in topic prioritization. Multivariate logistic regression models were used to determine associations between condition type and topic prioritization while controlling for participants’ sex, age, race, and Hispanic ethnicity. A Bonferroni correction was applied to account for multiple comparisons. Diagnoses of RICs included AS, axSpA, gout, JIA, SLE, myositis, polymyalgia rheumatica, PsA, RA, SS, or vasculitis. FM and osteoporosis were not included in the comparative analysis. SAS version 9.4 software (SAS Institute) was used for all statistical analyses.

RESULTS

Invitations were emailed to 1058 eligible members of PatientSpot to participate in the nominal groups. Emails were opened by 36.86% (390/1058) of recipients and 23.3% (91/390) of people who opened the email clicked to sign up. There were 47 participants in 6 nominal groups, and the majority were White women with RA (Supplementary Table S1, available with the online version of this manuscript). All nominal group participants were US residents, with mean age of 55 (range 30-74).

Nominal groups generated educational topics in participants’ own words. There were 47 participants in a total of 6 nominal groups (ranging from 4 to 10 people each). The first 5 groups generated 44 unique topics as important for people living with RMD to know about (Supplementary Table S2, available with the online version of this article). The sixth group did not generate any topics not identified by the previous groups, showing that a saturation of topics had been reached. Members of each group voted on which topics were first, second, and third most important to them. The expert panel used the card-sorting process to group these into 8 themes, which were then ranked in order of importance (Table 1). Knowledge of disease, coping, and knowledge of medications were the most important themes identified. Most themes pertained to patients’ knowledge about their disease, associated tests and treatments, and resources needed to obtain proper diagnosis, care, and treatment. Two themes, coping and communication, were related to patients’ holistic experience of living with the disease and the resources and behaviors required to optimally manage it.

Table 1.

Combined ranking of themes generated by nominal groupsa after eliminating duplicate topics and topics that received ≤ 5% votes within the nominal group that generated the topic.

Survey to prioritize educational topics and app functions for adults living with RMD. Survey invitations were emailed to 23,928 members of PatientSpot and CreakyJoints. Emails were opened by 34.59% (8276/23,928) of recipients, and 11.74% (972/8276) clicked the link to the survey. The survey was started by 925 individuals, and 805 (87%) met the inclusion criteria and completed the survey. Survey invitations were also emailed to 173,690 ENRGY patients and opened by 29.85% (51,839/173,690) of recipients. The survey was started by 10.72% (5558/51,839) of ENRGY patients, and 68.24% (3793/5558) of those who began the survey met the inclusion criteria and completed the survey.

The mean age of the 4598 (PatientSpot, n = 805; ENRGY, n = 3793) survey completers was 63.0 (SD 12.1) years, 79.38% were female, and 81.77% were White (Table 2). The average time since diagnosis was 12.9 (SD 11.9) years. Respondents with OA (n = 764) were slightly older than those with RIC (n = 3262; OA: 66.8 [SD 10.4] years, RIC: 62.1 [SD 12.2] years, P < 0.001). A greater proportion of the OA group was female (OA: 84.3%, RIC: 77.25%, P < 0.001).

Table 2.

Survey respondent demographic and clinical characteristics, by condition type.

The most highly rated educational topics were knowing when medication is not working (87.78%), finding the right rheumatologist (84.97%), knowing side effects and interactions of available drugs (84.62%), and understanding the results of tests used to monitor the condition (82.06%; Table 3). Respondents with RIC were less likely than those with OA to rate knowing about treatments (OR 0.64, 95% CI 0.52-0.80, P ≤ 0.001) or alternative therapies (OR 0.63, 95% CI 0.53-0.74, P ≤ 0.001), as extremely important (Supplementary Table S3, available with the online version of this article). Participants with an RIC were also less likely than those with OA to rate knowing where to find information about pain and fatigue as extremely important (OR 0.75, 95% CI 0.64-0.88, P ≤ 0.001).

Table 3.

Proportion of survey respondents that rated a topic as extremely important, by theme, educational topic, and condition type.

Regarding interest in a smartphone app for people living with RMD, ≥ 40% of all respondents indicated they would find it useful to view laboratory results (57.44%), record symptoms or disease flares to track health over time (43.80%), schedule and keep track of rheumatology and other medical appointments (42.76%), keep track of prescribed medications (39.91%), share recorded symptoms with their rheumatology provider to know if they are meeting treatment goals (38.95%), and get educational information about the disease (38.80%). Respondents with RIC vs OA more frequently rated recording and sharing symptoms with their rheumatology provider to track treatment goals (RIC: 40.25%, OA: 32.7%, P < 0.001) and tracking vaccination (RIC: 31.33%, OA: 24.2%, P < 0.001) as important (Table 4).

Table 4.

Features participants consider useful in a smartphone app for their rheumatologic condition, by condition type, ranked from most to least frequently endorsed.

The Figure shows smartwatch and/or activity tracker ownership and interest in ownership among all respondents. Approximately one-third (31.71%) owned and regularly used a fitness tracker; however, half (50.50%) did not own, nor did they plan to get, a smartwatch or activity tracker. There were no differences in ownership and interest by condition type.

Figure.

Proportion of patients who own and use a smartwatch or activity tracker (eg, Apple Watch, Fitbit, Garmin), by condition type.

DISCUSSION

Using a mixed-methods approach that included an online survey to validate and prioritize educational topics generated by NGT, respondents indicated their educational needs related to their RMD. More than 75% of respondents, regardless of whether they had an RIC or OA, rated 11 common items as extremely important and placed highest priority on knowing when medication is not working, understanding routine monitoring test results, and knowing about drug side effects and interactions. Among the few differences between respondents with RIC vs OA, those with RIC were less likely to rate knowing about all medication or other therapy options, including alternative treatments such as acupuncture, as extremely important. This perhaps reflects the dearth of available pharmacological therapies currently available for OA and indicates a desire among people with OA to be better informed about options to address the pain and limited mobility that accompany OA. In a potential smartphone app for RMD, respondents prioritized functions related to viewing their laboratory test results, tracking their disease and its symptoms, appointments, and medications, and sharing this information with their doctor. Although not prioritized to the same extent as tracking, receiving disease education through an app was also important to respondents. Notably, about half of respondents owned or indicated interest in owning a smartwatch and/or activity tracker.

To our knowledge, this is the first study of how people living with RMD in the USA express their educational needs in their own words. Notably, although the specific items differ, the domains identified are similar to domains used on the ENAT, which was developed in the United Kingdom and has been validated as a means of identifying the educational needs of patients with RMD in multiple languages and cultures, but not in the USA.3,4,28 Multiple studies have shown that patients desire education29-37 and both the ENAT and the results presented here show that people living with RMD need information about their disease, treatment options, disease monitoring, self-management of disease, shared decision making, and communication with their care teams.4,13 The results presented here also identified finding the right doctor and cost of care as important educational topics, which may reflect the payment and service health care model of the USA.

Multiple studies show that needs-based patient education improves short-term adherence to treatment, self-efficacy, and quality of life.5,6,38-45 Research is ongoing regarding how to extend these benefits over a longer timeframe and to a wider global population. Effective patient education with durable benefits is also important for shared decision making, patient-centered care, and involving patients in PCOR.28,39-47

In this mixed-methods study, we identified 2 potential changes to the content and delivery of patient education for RMD. Patient education, defined as, “any set of planned educational activities designed to improve patients’ health behaviors and/or health status,”46 has traditionally been assessed and provided by health professionals using education and language that is not always easily understood by patients, who instead retain, at best, the gist of what they hear.14 By identifying patients’ educational needs in plain language, it may be possible to develop educational interventions that do not require a patient to translate the healthcare professionals’ verbatim technical language into their own gist of the information. For example, a physician might say, “arthritis is a systemic disease,” whereas a patient is more likely to instead understand that “arthritis affects more than just joints; organs are also affected.” Alternatively, a physician might talk about being seronegative, but a patient would better understand, “you can have arthritis without having a positive test result” (Supplementary Table S2, available with the online version of this article).

Increasingly, however, people with chronic disease of any kind, including RMD, also seek information online or educate themselves without the guidance of healthcare providers.48 By identifying the education needs both of individuals who are involved in an online community for people with rheumatic conditions (PatientSpot) and of patients with internet connections being seen in community rheumatology practices (ENRGY), and by using plain language, we may be better able to provide educational materials for use both online and in clinical settings.

We also learned about activity-tracking device use in this population. An app specifically for people with rheumatic disease would enable multiple functions, research participation being just one example. Patient education that is responsive to data input from people living with RMD is technically feasible and appealing to some patients and physicians alike. Moreover, recent expansion of Centers for Medicare and Medicaid Services (CMS) reimbursement for remote therapeutic monitoring (RTM) in January 2022 now permits rheumatologists to bill insurance for the monitoring of their patients’ disease activity and symptoms over time.49 Physicians can now prescribe patients an RMD app and encourage them to provide symptom, disease activity, medication adherence, and other data between visits as required for RTM (eg, https://illumination.health/rtm/). In turn, patients could receive real-time recommended education modules and patient-friendly articles or podcasts that match their specific condition, medication(s), laboratory test results, level of disease activity, time to next appointment, phase of disease journey, and preferences. Our findings here demonstrate that many people living with rheumatic disease are interested in information about these topics and some may use a smartphone app to access it.

These findings should be considered in the context of the study’s limitations. Only people with internet access were included throughout the study. An online patient community was the recruitment source for nominal groups, so selection bias is a potential concern. One-third of people who were sent the invitation opened it, and thus nominal groups may have included people who were more actively involved in learning about their disease. However, it is unclear if patients more actively involved in their own care and disease management necessarily represent a biased group with respect to their desired educational needs. The majority of nominal group participants were White women with RA, so there may be other educational topics that a more diverse group of patients with RMD would generate. Moreover, minor refinement of topic phrasing was done to ensure the use of simple language for several survey items, and it is possible that unintended meanings may have been introduced as a result. Cognitive testing of final survey items was not conducted. Future research should include concept elicitation and cognitive briefing of survey items to ensure that all educational topics and other questions are relevant and understood by intended survey respondents. Further, as the survey population consisted predominantly of White women and information on the socioeconomic status of respondents was not collected, results may not be generalizable to other populations. Finally, survey respondents were not asked about prior use of smartphones or apps, and thus a minority of survey respondents may have based their answers about various app features on speculation rather than experience. According to a Pew Research Center study conducted in 2021, 95% of US adults aged 30 to 49 years, 83% of those aged 50 to 64 years, and 61% of those aged ≥ 65 years reported owning a smartphone.50 Therefore, a more heterogenous group of respondents that includes individuals without internet connectivity and distinguishes between those with and without prior smartphone app experience may prioritize educational topics and smartphone app features differently. Nonresponse bias is a strong possibility since respondents opted in to survey participation after receiving an email invitation. Nevertheless, this study offers guidance for those designing and disseminating rheumatology patient education content and conducting future research in this area.

In conclusion, using a structured mixed-methods research design, we determined that a population of predominantly White, female US patients with various rheumatic conditions who participated in a digital registry prioritized information about laboratory tests, medications, and disease and symptom monitoring. This guidance can be used to create educational and digital tools to support people living with rheumatic diseases during their disease journey and to be responsive to data provided by patients and their doctors. Further research is needed to determine whether these items and themes reflect patient educational needs and smartphone app interests in more heterogeneous RMD populations. Additionally, interventions that disseminate the identified educational topics and smartphone app features should be developed and tested. Ultimately, further research using these patient-generated topics is warranted to determine whether effective dissemination of patient education using the words and priorities of people living with rheumatic conditions positively affects outcomes, including treatment adherence, quality of life, patient-centeredness, and health outcomes.

ACKNOWLEDGMENT

The authors thank Vandana Dronadula for her assistance in formatting an early version of this manuscript, including tables and figures, and Patrick J. Stewart and Fenglong Xie of Illumination Health for help with survey recruitment. We also thank members of the PatientSpot registry (formerly ArthritisPower) and patients in the care of rheumatology providers of the Excellence Network in Rheumatology (ENRGY), for their time and willingness to participate in this study. William B. Nowell contributed to this article as an employee of Global Healthy Living Foundation and the views expressed do not necessarily represent the views of Regeneron Pharmaceuticals Inc.

Footnotes

This study was funded by the Global Healthy Living Foundation (GHLF). GHLF receives grants, sponsorships, and contracts from pharmaceutical manufacturers and private foundations. A full list of GHLF funders is publicly available here: https://ghlf.org/partners/. Infrastructure support for the PatientSpot (formerly ArthritisPower) registry was provided in part by the National Institute of Arthritis and Musculoskeletal and Skin Diseases award no. P30AR072583.

WBN was the principal investigator on grants/contracts from AbbVie, Amgen, Janssen, and Scipher Medicine; was an employee of the Global Healthy Living Foundation (GHLF), a not-for-profit patient advocacy organization, at the time this study was conducted and article was written; and is currently an employee of Regeneron and a shareholder of Regeneron stock. K. Gavigan, SV, LS, and ER are employees of GHLF. MS is the owner of MedExplain, a company commercializing a patient education platform. MG receives research funding from GSK and personal fees from AbbVie. AO has served as a consultant for AbbVie, Amgen, BMS, Celgene, CorEvitas, Gilead, GSK, Happify Health, Janssen, Lilly, Novartis, Pfizer, and UCB, and has received grants to the University of Pennsylvania from AbbVie, Janssen, Pfizer, Novartis, and Amgen. JAW receives grants from AbbVie, Merck, and Pfizer, and has received personal fees from AbbVie, Amgen, Eli Lilly, Janssen, Novartis, Pfizer, and UCB. MID has received research funding from Pfizer and serves as a consultant at UCB. JRC receives grants and personal fees from AbbVie, Amgen, BMS, CorEvitas, Eli Lilly, Janssen, Myriad, Pfizer, Regeneron, Roche, and UCB, and personal fees from Gilead, Novartis, and Samsung. The remaining authors declare no conflicts of interest relevant to this article.

Accepted for publication April 29, 2024.Copyright © 2024 by the Journal of Rheumatology

This is an Open Access article, which permits use, distribution, and reproduction, without modification, provided the original article is correctly cited and is not used for commercial purposes.