Quality of Health Care for Rheumatoid Arthritis Patients: Another Vote Cast in Favor of Rheumatologists
October 2000
Rheumatoid 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.
1355 patients 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.
October 18,
2000
John J. Cush, MD, and Robert
Spiera, MD
Hotline Editors
*MacLean 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.
