Although patients with rheumatoid arthritis (RA) are most often cared for by both primary care providers (PCPs) and rheumatologists, preventive screening remains suboptimal (1, 2), and the mortality gap between RA patients and their peers has widened (3, 4). Cardiovascular disease (CVD) is the leading cause of death in patients with RA. These patients experience a 10-year risk of CVD events that is 50–60% higher than that in their age-matched peers (5, 6). The reductions in rates of death from cardiovascular causes seen in the general population in recent decades (7) have not been seen among patients with RA (3–5), and cardiovascular risk has not equilibrated even with aggressive RA treatments (8). Consequently, adequate screening for traditional CVD risk factors is strongly indicated for RA patients.
Primary preventive screening before the onset of CVD is key to identifying modifiable traditional CVD risk factors. To date, the performance of primary preventive lipid screening, meaning testing before the onset of CVD, CVD risk equivalents, or established hyperlipidemia, has not been systematically examined in a national RA sample. Compounding the challenge, no widely known RA-specific preventive guidelines for CVD exist despite increased CVD risk in RA. The European League Against Rheumatism (EULAR) has issued recommendations for an annual CVD risk review (9). For all adults, the National Cholesterol Education Program (NCEP) recommends lipid screening in those with CVD risk factors “more frequently than every 5 years” (10).
Prior reports suggested that RA patients frequently experience unidentified and uncontrolled traditional modifiable CVD risk factors, including hyperlipidemia and hypertension (11–13). Although it has not been studied specifically in RA, according to the recent Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) study, elevations in the C-reactive protein level may also merit consideration of lipid-lowering therapy (14, 15). RA patients see multiple physicians annually, with rheumatology visits often outnumbering primary care encounters (16). The influence of multisource care and competing comorbidities raises questions of whether the process of care can be optimized to improve primary preventive screening for patients with RA and other chronic conditions (17). Older adults in particular are receiving aggressive treatment for RA (18) but are at greatest absolute risk of coronary events. They may also be most vulnerable to lapses in preventive care due to competing comorbidities and multisource care. As a result, older RA patients represent a key target population for CVD risk factor modification.
In the present study, we investigated the impact of rheumatology and primary care outpatient visit patterns upon primary preventive lipid screening among a group of older adults with RA. We specifically examined whether individual likelihood of lipid screening differed by types of providers seen each year as well as the relative proportions of visits to PCPs and rheumatologists. Reflecting the more conservative NCEP recommendation versus the EULAR recommendations, we examined lipid screening over a 3-year window.
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- PATIENTS AND METHODS
- AUTHOR CONTRIBUTIONS
Recognizing CVD as the leading cause of death in RA, we sought to examine primary preventive screening for hyperlipidemia as a modifiable cardiac risk factor among RA patients in relationship to primary care and rheumatology outpatient visits. Overall, lipid testing occurred in fewer than half of all those who were eligible over 3 years. Patients with lone rheumatologic care had substantially less lipid screening as compared to patients with any primary care: 22% for Lone Rheum versus 43–51% for other visit patterns that included at least some primary care. Those who saw a PCP at least once each year fared best, with 51% undergoing testing. This finding was consistent with a study done in 2000, in which lower routine cancer screening among RA patients without primary care contact was reported, and with a 2010 study examining multiple preventive services in RA (1, 26). However, in our study, even with primary care involvement, the observed rates of lipid screening remained poor regardless of visit proportions, suggesting a need to systematically improve preventive cardiovascular care for patients with RA.
We found that primary lipid screening for RA patients was significantly less frequent than the rates reported among average ambulatory Medicare beneficiaries, which has been estimated at 50–55% each year (36). Our low observed rate of screening performance also contrasts with the aforementioned 2010 RA study that reported 5-year lipid testing performance of 83.5% (26). However, that study did not separately examine primary versus secondary CVD risk screening populations or control for prevalent hyperlipidemia, CVD, or risk equivalents. Maintenance testing among secondary prevention populations, as compared with actual primary lipid screening, likely inflated the observed rates in that study, although longer observation may have also influenced the results. Performance in our primary prevention RA cohort was more analogous to screening in younger average-risk HMO populations, whose 3-year LDL testing frequency was ∼40% (37). The observed screening performance rates being below the rates in general HMO and Medicare populations suggest that RA patients were not receiving routine screening. This suggests possible impediments to routine care delivery, uncertainty regarding the complex relationship between lipids and CVD risk in RA (38, 39), or underrecognition of RA itself as a cardiovascular risk factor.
In our study, other predictors of poor rates of lipid screening demonstrate opportunities for improving care in RA patients who are older, sicker, and have the fewest outpatient visits. Patients with more visits and a higher number of unique providers were more likely to be screened, which is consistent with a study showing that relevant specialist involvement may improve screening in patients with complex conditions (40). Conversely, the finding of low rates of screening among patients from large towns may reflect lower provider density, or it may reflect smaller group practices that report lower quality than larger group practices (29).
Universally, addressing the elevated risk of CVD from inflammatory arthritis requires additional knowledge and vigilance to capture care delivery opportunities. In our sample, half of the RA patients saw their rheumatologist at least as often as they saw their PCP, and other studies have suggested that rheumatology encounters often outnumber PCP visits (16). Rheumatologists may feel that prevention is the role of primary care providers and may not want to interfere, even though they may be more familiar with CVD risk in relation to RA. PCPs may be stretched to invoke disease-specific prevention in limited encounters with patients who are also receiving specialty care. Coordinating the expertise of both the rheumatologist and the primary care provider may be useful in improving preventive cardiovascular care.
Collaboration with specialists has been shown to improve the quality of preventive care in patients with complex conditions (41, 42); this collaboration may mitigate the common finding that patients with competing comorbidities often receive less preventive care than healthier patients do (17, 40). One multispecialty health network with a well-integrated electronic health record reported superior lipid and osteoporosis screening among patients with RA as compared to the total network cohort, suggesting that optimal system support and multispecialty collaboration can enhance health care delivery to complex populations (43).
An optimal partnership between rheumatologists and primary care providers to address cardiovascular risk has not been defined. Rheumatologists are familiar with the disease-specific risks of RA and could play a more active role in this process. Rheumatologists could educate patients and primary care clinicians regarding increased CVD risk in RA or could actively order screening and/or co-manage modifiable risk factors. For instance, in contrast to the low frequency of lipid screening noted in our study, one academic rheumatology clinic that implemented routine screening practices reported 88% lipid testing at 5 years, highlighting the potential impact of specialty-driven protocols (44). A pivotal parallel example of shifting prevention roles is the move in recent years to include osteoporosis within the relevant scope of specialty practice. Studies have demonstrated that screening rates and treatment of routine and glucocorticoid-induced osteoporosis improve with rheumatologist collaboration (45, 46). Moreover, the 2010 study examining multiple evidence-based preventive services in RA showed that combined rheumatology and primary care predicted higher overall performance (26). Our finding of improved lipid testing among those who saw a PCP at least once each year may suggest a role for rheumatologists to advocate annual PCP visits for RA patients.
Formal specialist roles have also been examined amidst the expanding dialogue regarding the “patient-centered medical home” (47, 48). The American College of Physicians (ACP) identifies rheumatologists caring for RA patients as a possible specialty-based medical home if first-contact, whole-person, continuous, and integrated care is provided. However, the ACP Committee of Subspecialty Societies proposed an alternative specialist role as a “medical neighbor,” expanding the previous idea of a coordinated health care system as a “medical neighborhood” (49). As medical neighbors, specialists are not required to assume first-contact primary care responsibilities, but to promote co-management within the health system (47). As such, rheumatologists may advocate annual PCP visits or may co-manage cardiovascular prevention as good medical neighbors without assuming all primary care responsibilities. As research regarding the patient-centered medical home expands and health systems increasingly assume responsibility for promoting health among populations, the role of specialists as medical neighbors for cardiovascular preventive care should be explored further.
As with any scientific analysis, this study has some limitations. First, there is the potential for misclassification of RA and other diagnoses. To address this concern, previously validated algorithms were used (1, 19). Although the strictest validation study used only rheumatologist-reported RA coding (19), which demonstrated high correlation with audited ACR criteria, we adopted the convention of subsequent authors who used the criterion of more than 1 RA code in 24 months (1, 2, 18) to ensure that RA patients exclusively receiving primary care were included. Misclassification of osteoarthritis (OA) as RA may have occurred more frequently in the lone primary care group, but the low screening rates appear to be consistent with the rates among those receiving combined rheumatology and primary care, suggesting that if OA patients were included, it did not appear to have influenced the observed screening rates.
Second, there may be unmeasured differences between patients who see only a rheumatologist, such as patient preferences. We approached this concern by limiting our scope to primary prevention, stratifying and adjusting for a wide range of variables, including number of visits, unique providers, overall comorbidity, and RA severity surrogates, although data on RA disease activity measures and treatments were not available. We found that the lone rheumatology group was least likely to receive orthopedic surgery or gait devices, suggesting that they did not have historically worse RA to justify lapsed screening. However, in the absence of acute disease activity measures or medications, we cannot exclude rational delays in screening, given lipid fluctuations in patients with acute inflammation and steroid treatment (39).
We also acknowledge that ICD algorithms may underestimate hyperlipidemia if patients receive medications without the diagnosis being coded. Quality measures recommend annual lipid testing among such secondary prevention patients, even with statin treatment, so poor screening among potentially misclassified secondary risk patients receiving statins would reflect even more poorly.
Third, our study sample was limited to older adults with RA prior to 2006. It is unclear whether our results are generalizable to younger patients or to more recent years. However, it remains possible that with less comorbidity triggering health system contacts, younger RA patients may have even lower rates of lipid screening.
Finally, given that current RA-specific recommendations for CVD prevention are not explicit and that the exact role of lipids in CVD risk may be nonlinear, our choice of a 3-year versus a 5-year window for assessing lipid screening could be questioned (12, 14). It is unlikely, however, that the observed poor rates of screening would drastically improve by using a 5-year window. As a simple exercise, if we consider our screening rate over 3 years, the inclusion of 2 more years boosts screening rates to 71% at best, still leaving more than 1 in 4 RA patients unscreened. Future studies could examine a longer period and should include a comprehensive assessment of all traditional CVD risk factors, as well as actual CVD outcomes.
In this primary CVD prevention cohort of RA patients, lipid screening was frequently overlooked. When examining visit patterns, as long as a primary care provider was involved, no significant difference in screening probabilities emerged, regardless of the balance between primary care and rheumatology specialty care. A 22% improvement in testing among those seeing a PCP at least once each year suggests a role for advocating annual PCP visits for patients with RA, although performance improved only to 51% in the group seeing a PCP at least once a year. The remaining gap suggests that lapses in prevention may be one potential mechanism explaining why patients have not fully benefitted from declines in CVD seen in the general population despite aggressive treatment for the RA (3–5, 7). The observed gap in lipid screening highlights a key target for CVD risk reduction efforts. In addition, the finding that half of RA patients see their rheumatologist at least as often as they see their PCP suggests a need to study optimal partnerships between primary care providers and specialists for screening for CVD risk factors in high-risk populations within their medical homes and neighborhoods.