of Health Care for Rheumatoid Arthritis Patients: Another Vote Cast in Favor
arthritis (RA) is a chronic disabling disorder with substantial comorbid disease
associations. Rheumatologists manage only a minority of RA patients, and, for
many patients, there are numerous impediments to specialty care input and/or
referral (e.g., gatekeeper model, lack of insurance or lack of rheumatologists).
This issue is compounded by a lack of unbiased studies that clearly indicate
the impact of physician specialty on the quality of RA health care. A recent
study in the August 23/30 issue of JAMA by MacLean et al* examines a large cohort
of RA patients and compares the quality of care delivered by relevant specialists
and primary care generalists. This study tested 3 hypotheses: 1) RA patients
received higher quality care for RA than for prevention or treatment of comorbidities;
2) specialists deliver higher quality care for arthritis, comorbid disease and
health maintenance; and 3) patients treated by a combination of specialists
and PCP received the highest quality care.
This was a
historic cohort study of adult RA patients enrolled in a national fee-for-service
or discounted fee-for-service insurance plan between 1991 and 1995. Information
was drawn from 3 data files: 1) demographic; 2) claims submitted (inpatient/outpatient
services, diagnoses, etc); and 3) pharmacy (prescribed medications). Patients
were required to have > 2 visits and > 2 claims at least 2 months apart and
a diagnosis of RA based on appropriate ICD-9 coding. Patients were not required
to have been seen by a rheumatologist or to meet ACR criteria for the diagnosis
of RA. The authors indicate that the positive predictive value of ICD-9 coding
for RA is 57-95%. Quality of care was not assessed by traditional outcome measures,
but rather by process measures (or standards of care) as established by the
ACR, American College of Cardiology (ACC), American Diabetes Association (ADA),
etc. Patients were analyzed as to whether they were eligible to receive 39 different
process measures for each of these 3 domains of care - arthritis, comorbid conditions,
and health maintenance. Aggregate performance scores represent the percentage
of recommended procedures done per patient-year.
were followed for 4598 person-years or a mean of 3.9 years. For all domains
of health care, 45-67% of the 4598 person-years analyzed were without the services
of a relevant specialist. This study demonstrated that RA quality of care was
insufficient and varied according to type of medical care. Overall aggregate
scores were 62% for arthritis care, 52% for comorbid disease care and 42% for
health maintenance care. Across all domains, care that included relevant specialists
yielded performance scores that were 30% to 187% higher than those without (P<0.001).
In contrast, PCPs were superior to rheumatologists in health maintenance measures.
This study supports the role of specialists, including rheumatologists, in the
management of RA patients. Moreover, it appears patterns of health care that
rely heavily on the PCP to care for patients with highly complex conditions
such as RA are suboptimal with regard to all domains of care.
John J. Cush, MD, and Robert
CH, Louie R, Leake B, McCaffrey DF, Paulus HE, Brook RH, Shekelle PG. Quality
of care for patients with rheumatoid arthritis. JAMA 284: 984-992, 2000.
Hotline is provided by
the ACR Communications and Marketing Committee as a service to members. This
Hotline reflects the views of the author(s) and does not represent a position
statement of the College.
Previous | Index | Next