- Top of page
- PATIENTS AND METHODS
Rheumatoid arthritis (RA), a chronic inflammatory arthritis, leads to high levels of pain, functional disability, decreased ability to work, and premature mortality (1). Standards of care have been established for its treatment (2–5). Disease-modifying antirheumatic drugs (DMARDs) reduce joint destruction and long-term physical disability (6–8). Delays, as brief as 3 months, in instituting DMARDs have been associated with poorer long-term outcomes, including greater physical disability (9–11) and increased radiologic damage (12–14). Therefore, treatment with DMARDs is recommended in all RA patients with active disease (3), and treatment paradigms have shifted towards early, aggressive, and persistent use of DMARDs with the aim of eradicating inflammation, thereby preventing joint damage (15–17).
Guidelines recommend early referral to a rheumatologist when a diagnosis of RA is suspected, for definitive diagnosis and early treatment with DMARDs (4, 5), and continued involvement of a rheumatologist to assess response to treatment and review the treatment plan (3). When rheumatologists are involved, quality of RA care (18) and outcomes (19–21) are improved, at no increased cost (22). Rarely is compliance with recommended guidelines assessed at the population level; however, this is essential to determine the quality of health service provision. In this study, we examined care received by the RA population of the province of British Columbia, Canada as captured by provincial health administrative databases, and compared it with recommended guidelines (2–5), focusing on DMARD treatment and specialist care.
The specific objectives were to evaluate whether DMARD use at the population level meets recommended guidelines by measuring the proportion of patients treated with DMARDs, the timeliness of starting DMARDs, the consistency of long-term DMARD use, and the frequency of use of combination therapy; to measure the proportion of the RA population treated by a specialist (rheumatologist or internist) and evaluate the impact on process of care; and to identify the determinants of DMARD use and care provided by a specialist.
- Top of page
- PATIENTS AND METHODS
This study assessed patterns of care received by all patients with RA in the province of British Columbia, Canada, where access to health care is universal. Although our study did not assess all aspects of current RA treatment guidelines, our results clearly point to important gaps in care. Of particular concern, the use of DMARDs, essential for the treatment of active RA, was unacceptably low, with less than half the RA population having ever received a DMARD over 5 years. When dispensed, DMARDs were started in a timely fashion, but were not used consistently and combination therapy was infrequent. Care by a rheumatologist greatly increased DMARD use. Unfortunately, less than half of the patients saw a rheumatologist.
Use of DMARDs was not consistent with current clinical guidelines when internists or family physicians were the sole providers of RA care. Rates of DMARD use at 40% and 10%, respectively, are much lower than would be expected, even when taking into consideration an RA population with milder disease. Lack of followup with a rheumatologist (people who switched from rheumatologist to family physician care for their RA) was associated with suboptimal DMARD use. Continuous, rather than intermittent, involvement of rheumatologists improved compliance with guidelines. DMARDs were used most frequently, most consistently, and most often in combination with continuous rheumatologist care. The similarly high rates of NSAID use and physiotherapy across the 4 care groups indicate that most RA patients followed by family physicians had active disease, which, according to current guidelines, warrants DMARD use. Finally, the similar rate of orthopedic surgery indicates that some of the patients followed by family physicians had sufficiently severe disease to require surgery, including arthroplasty.
The results of our study suggest that the paradigm shift to early, aggressive, and sustained use of DMARDs, well known to rheumatologists, has not reached family physicians, as evidenced by their frequent use of NSAIDs and physiotherapy but infrequent use of DMARDs, a pattern reminiscent of the pyramid approach. Yet, family physicians followed at least half of the RA population. There is an urgent need for continuing medical education efforts, aimed at family physicians, emphasizing the necessity of DMARD treatment for all RA patients with active disease. Targeting education at consumers directly may be a more effective approach. Furthermore, the surprisingly small proportion of RA population receiving care by rheumatologists, despite universal access to health care, suggests a need for greater rheumatologist manpower and access.
The prevalence of RA in our sample (0.76%) was consistent with epidemiologic studies. In a review, prevalence rates ranged from 0.5% to 1.1%, with an average of 0.8% (26). The concordance of our prevalence rate suggests that the under treatment of RA observed in our cohort was not due to unintentional inclusion of large numbers of non-RA cases. Although some non-RA cases may have been included, they would not be sufficient in number to explain the large gap in DMARD use observed.
To our knowledge, this is the first published report assessing whether treatment guidelines for RA are applied at the population level. Our rate of DMARD use is consistent with that observed in people over age 65 in the Canadian province of Ontario (27). Our results also confirm those of nonpopulation-based studies comparing process and outcome of RA care according to specialist involvement. MacLean et al (18) also found process of care for RA to be more favorable when rheumatologists were involved, although pattern of DMARD use and other treatments was not assessed. Ward et al (19) reported that continuous rheumatologist involvement, compared with intermittent, was associated with more intense DMARD treatment. Two studies on the same patient population reported less favorable outcomes (20) and decreased likelihood of treatment with DMARDs and prednisone (21) when care was provided by nonrheumatologists rather than rheumatologists. These studies in conjunction with ours point to the need for continued rheumatologist involvement on at least a semiannual basis.
Potential limitations of our study deserve comment. They include those inherent to data from administrative databases. Uncertainty around diagnosis accuracy is the main limitation of studies identifying cases from administrative databases. Most studies in RA used case definitions based on a single visit. We used the strictest published case definition, based on 2 visits at least 2 months apart (18), which was validated against self report of a physician diagnosis of RA, yielding a positive predictive value of 0.92 (28). We further improved specificity with additional exclusions. Our data on use of DMARDs refer to medications dispensed rather than prescribed or consumed. Our analyses do not control for differences in disease severity. It is probable that family physicians treat milder RA, explaining part of the lower rate of DMARD use. However, 10% DMARD use is lower than expected, even in milder disease. Given that family physicians follow half of the RA population, one would expect more than 10% to have sufficiently active and severe disease to require DMARDs. Furthermore, the similar rate of orthopedic surgery across care groups suggests that some of the patients followed by family physicians had severe disease. Finally, while guidelines recommend that all RA patients with active inflammation be treated with DMARDs, the high rate of NSAIDs and physiotherapy use suggests that the disease of people followed by family physicians was active.
Strengths of our study include the involvement of an entire population of RA, in the context of a universal health care system, where no physicians can opt out, as well as the accurate and complete capture of health services use from administrative databases, including all medications, regardless of age and source of funding.
In conclusion, data from our population-based cohort of RA with universal health care access indicate that patterns of RA care are not consistent with current treatment guidelines and point to important gaps in care. More specifically, use of DMARDs and care by rheumatologists were inappropriately low. While none of the physician care groups had universal use of DMARDs, gaps in DMARD treatment were greatest in people whose RA care was provided solely by family physicians, which represented approximately half of the RA population. RA care was improved when rheumatologists were involved continuously rather than intermittently. Given that DMARDs are essential in the treatment of RA and have been demonstrated to impact long-term joint damage and physical function, the findings are alarming. Efforts to educate family physicians and consumers about the shift in RA treatment paradigms and to improve access to rheumatologists are needed urgently.