Patients with rheumatoid arthritis (RA) frequently develop comorbid conditions, which can be detected and managed through enhanced screenings and preventive medical care, such as immunizations. In Canada to date, quality measures for the screening and management of comorbidities in these patients have focused on care provided by rheumatologists. But what about primary care physicians, who are essential to disease prevention and to supporting rheumatologists?
New research by Jessica Widdifield, PhD, and colleagues from the Institute for Clinical Evaluative Sciences, Toronto, ON, Canada, examined the management of comorbidity in RA patients within the primary care setting. Researchers developed and assessed quality measures related to screenings, process and outcome measures for patients both with and without RA. The results of this work were published in October 2017 Arthritis Care & Research.
Using data from the primary care Electronic Medical Record Administrative Data Linked Database (EMRALD) in Ontario, researchers harmonized the Canadian general population and RA clinical recommendations. From the database, 154,388 eligible patients from 209 primary care physicians were identified. For each RA patient, 10 non-RA patients were matched by age and sex, resulting in patients with a similar prevalence for comorbid conditions, such as hypertension, ischemic heart diseases and diabetes mellitus. In total, 1,405 RA patients were compared with 14,050 matched non-RA patients. Stratified analyses were performed, comparing patients with RA to those without RA, to assess the performance of these quality measures.
The Results
“Ontario primary care physicians tend to provide similar quality of care for patients with and without RA, but the performance of many process measures was suboptimal in both RA and non-RA patients,” write the authors in their discussion. “Many RA patients do not receive optimal preventive medical services, such as immunizations and screening for comorbid conditions.”
For general preventive care, RA patients were more likely to have been to their primary care physician within the past year, as well as to have undergone testing for bone mineral density, than non-RA patients. RA patients were also slightly more likely to receive vaccinations for influenza (44.9% vs. 40.0%) and pneumococcal pneumonia (40.4% vs. 34.1%) than non-RA patients. However, herpes zoster vaccinations were less frequent among RA patients than non-RA patients. RA patients also received less screenings for cervical cancer (58.6% vs. 64.0%) than non-RA patients. But no significant differences were observed between RA and non-RA patients in screenings for breast (70.7% vs. 73.8%) or colorectal (31.7% vs. 34.5%) cancers.
Regarding cardiovascular risk factors, only a quarter of RA patients received all assessments for blood pressure, lipids, glycosylated hemoglobin and BMI. “[Because] RA increases the risk for cardiovascular events, it is imperative that primary care physicians understand and more aggressively manage cardiovascular risk in these patients,” write the authors. “This underscores the important role of family doctors in the comanagement of these conditions, and our findings indicate several areas in which primary care for RA patients could be improved.”
For hypertension, a similar number of patients had a blood pressure reading exceeding the cutoff target of greater than 160/100 mm-Hg, 6.1% of RA patients vs. 5.4% of non-RA patients. Also, 5.3% of RA patients vs. 3.9% of non-RA patients with ischemic heart disease had a blood pressure readings exceeding 160/100 mm-Hg, and less than half of patients had a low-density lipoprotein cholesterol measurement of less than 2.0 mmol/L—42.0% in the RA group vs .47.3% in the non-RA group. (Note: No significant difference was detected in the management of diabetes mellitus between RA and non-RA patients with the condition.)
The authors emphasize the importance of understanding the screening and care practices used in the primary care setting to develop targeted strategies to prevent comorbidities in RA patients and improve care. “Our findings suggest a need for clear guidelines for rheumatologists and primary care providers regarding comanagement of comorbidities in patients with RA,” they conclude.
Widdifield J, Ivers NM, Bernatsky S, et al. Primary care screening and comorbidity management in rheumatoid arthritis in Ontario, Canada. Arthritis Care Res (Hoboken). 2018 Oct;69(10). doi: 10.1002/acr.23178.
