Patterns of preventive health services in rheumatoid arthritis patients compared to a primary care patient population

The use and context of the term 'multimorbidity' in rheumatoid arthritis: a systematic literature review

This systematic literature review aimed to analyse terms describing coexisting conditions in the RA literature, informing the need for an operationalized definition of multimorbidity. Articles discussing RA with multimorbidity, published 1946 until August 2020, were identified. The primary outcome was the use and/or definition of 'multimorbidity' in RA. Information extracted included terms defining coexisting conditions, the use of a comorbidity/multimorbidity score and the use of 'index disease' to describe RA (more applicable to comorbidity than multimorbidity). Thirty-nine articles were included. Eight articles used the term 'multimorbidity', 18 used 'comorbidity' and 12 used both terms, 7 synonymously. One used no term. Fourteen articles fully defined the term. The number of co-existing conditions described in included studies was one-121. Twelve articles used a comorbidity/multimorbidity score. Four articles described RA as the 'index disease'. Our results demonstrate inconsistent use of the term multimorbidity. Improved assessment of multimorbidity is indicated in RA patients, including an operationalized use and definition.

Uptake of Preventive Services Among Patients With and Without Multimorbidity

INTRODUCTION

Patients with multiple chronic conditions (multimorbidity) are seen commonly in primary care practices and often have suboptimal uptake of preventive care owing to competing treatment demands. The complexity of multimorbidity patterns and their impact on receiving preventive services is not fully understood. This study identifies multimorbidity combinations associated with low receipt of preventive services.

METHODS

This was a retrospective cohort study of U.S. community health center patients aged ≥19 years. Electronic health record data from 209 community health centers for the January 1, 2014-December 31, 2017 study period were analyzed in 2018-2019. Multimorbidity patterns included physical only, mental health only, and physical and mental health multimorbidity patterns, with no multimorbidity as a reference category. Electronic health record-based preventive ratios (number of months services were up-to-date/total months the patient was eligible for services) were calculated for the 14 preventive services. Negative binomial regression models assessed the relationship between multimorbidity physical and/or mental health patterns and the preventive ratio for each service.

RESULTS

There was a variation in receipt of preventive care between multimorbidity groups: individuals with mental health only multimorbidity were less likely to be up-to-date with cardiometabolic and cancer screenings than the no multimorbidity group or groups with physical health conditions, and the physical only multimorbidity group had low rates of depression screening.

CONCLUSIONS

This study provided critical insights into receipt of preventive service among adults with multimorbidity using a more precise method for measuring up-to-date preventive care delivery. Findings would be useful to identify target populations for future intervention programs to improve preventive care.

Changes in Care After Implementing a Multifaceted Intervention to Improve Preventive Cardiology Practice in Rheumatoid Arthritis

Rheumatoid arthritis (RA) increases cardiovascular disease (CVD) risk. However, CVD risk factor identification and treatment is often inadequate. The authors implemented a multifaceted rheumatology practice intervention to improve CVD risk factor measurement, assessment, and management. The intervention included clinician education, point-of-care decision support, feedback, and care management. The authors measured quality indicators from electronic health records and assessed impact with interrupted time series. Following the intervention, more RA patients had all major CVD risk factors assessed (53% vs 72.2%), and the rate of increase was greater during the intervention period than baseline (difference of 0.74% per month, P = .0016). Moderate- or high-intensity statin prescribing increased (21.6% to 28.2%), but the rate of change was not different from baseline. Several other quality measures did not increase. Although CVD risk factor assessment improved, the intervention did not affect risk factor management and control. Other strategies are needed to optimize CVD prevention in RA.

Translation and adaptation of the French version of the Heart Disease Fact Questionnaire - Rheumatoid Arthritis (HDFQ-RA 1&2)

OBJECTIVES

Rheumatoid arthritis constitutes a cardiovascular risk factor as significant as diabetes, yet remains insufficiently managed. The Heart Disease Fact Questionnaire - Rheumatoid Arthritis (HDFQ-RA1&2) is a self-questionnaire that assesses patients' general knowledge about cardiovascular risk and more specifically associated with rheumatoid arthritis and its treatments. Objectives are to translate and adapt the HDFQ-RA into French and assess its psychometric properties in order for it to be used as instructional material by nurses in therapeutic education.

METHODS

The questionnaire was translated into French and subsequently back-translated into English pursuant to the "Guidelines for the process of cross-cultural adaptation of self-report measures". Psychometric properties were evaluated in a sample of 60 rheumatoid arthritis patients (test-retest procedure) between June and December 2013. Item content, factor analysis, and Kuder-Richardson's-alpha were used to evaluate acceptability, internal consistency, and reproducibility.

RESULTS

A culturally acceptable version for French patients was obtained. Cronbach's-alpha coefficient was higher than the usual recommended value of 0.6. Reproducibility was good (agreements measured by Kappa's coefficient >0.56 [recommended value=0.4]). Results showed that knowledge of cardiovascular risk was generally satisfactory (rate of correct responses ≥60%), but specific knowledge of the cardiovascular risk associated with rheumatoid arthritis remained poor, e.g. knowledge of the increased risk associated with rheumatoid arthritis (40% correct responses), higher risk with active rheumatoid arthritis, adverse effect of rheumatoid arthritis on lipid profile and the effects of corticosteroids and NSAIDs on cardiovascular risk.

CONCLUSIONS

The French-HDFQ-RA is valid for assessing patient knowledge of cardiovascular risk in general and associated with rheumatoid arthritis and its treatments.

Utilization of Preventive Health Care in Adults and Children With Eczema

INTRODUCTION

Chronic disease is a barrier to delivery of preventive health care and health maintenance. However, health behaviors of adults and children with eczema, a chronic skin disorder, have not been examined. This study examined associations of eczema with vaccination, disease screening, health maintenance, and healthcare utilization.

METHODS

This study investigated 34,613 adults and 13,298 children from the 2012 National Health Interview Survey, a prospective questionnaire-based study. Data were analyzed between August 2014 and January 2015.

RESULTS

Adult eczema was associated with higher odds of vaccination for tetanus (OR [95% CI]=1.37 [1.22, 1.54]); influenza (1.23 [1.10, 1.37]); hepatitis A (1.21 [1.04, 1.41]) and B (1.21 [1.07, 1.35]); human papilloma virus (1.66 [1.32, 2.08]); and pneumonia (1.35 [1.19, 1.54]), but not herpes zoster virus (1.07 [0.87, 1.31]). Adult eczema was associated with increased measurement of blood glucose (1.29 [1.16, 1.44]); cholesterol (1.19 [1.06, 1.34]); blood pressure (1.84 [1.56, 2.08]); and HIV infection (1.50 [1.34, 1.70]), but not Pap smears (1.11 [0.95, 1.30]); colon cancer screening (p=0.17); or mammograms (p=0.63). Adults with eczema were more likely to interact with general doctors, mid-level providers, mental health professionals, eye doctors, podiatrists, chiropractors, therapists, obstetrician/gynecologists, and other specialists (p≤0.01). Childhood eczema was associated with higher rates of vaccination for influenza (p<0.0002); well child checkups (p=0.002); and interaction with most types of healthcare providers (p≤0.01). Many associations remained significant in multivariate models controlling for sociodemographics and healthcare interaction frequency.

CONCLUSIONS

Eczema in adults and children is associated with greater utilization of preventive health care and health maintenance, but not cancer screening.

A systematic review of validated methods for identifying patients with rheumatoid arthritis using administrative or claims data

PURPOSE

To review the evidence supporting the validity of billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify patients with rheumatoid arthritis (RA) in administrative and claim databases.

METHODS

We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to RA and reference lists of included studies were searched. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria and extracted the data. Data collected included participant and algorithm characteristics.

RESULTS

Nine studies reported validation of computer algorithms based on International Classification of Diseases (ICD) codes with or without free-text, medication use, laboratory data and the need for a diagnosis by a rheumatologist. These studies yielded positive predictive values (PPV) ranging from 34 to 97% to identify patients with RA. Higher PPVs were obtained with the use of at least two ICD and/or procedure codes (ICD-9 code 714 and others), the requirement of a prescription of a medication used to treat RA, or requirement of participation of a rheumatologist in patient care. For example, the PPV increased from 66 to 97% when the use of disease-modifying antirheumatic drugs and the presence of a positive rheumatoid factor were required.

CONCLUSIONS

There have been substantial efforts to propose and validate algorithms to identify patients with RA in automated databases. Algorithms that include more than one code and incorporate medications or laboratory data and/or required a diagnosis by a rheumatologist may increase the PPV.

Cardiovascular screening in rheumatoid arthritis: a cross-sectional primary care database study

Background

Patients with rheumatoid arthritis (RA) are known to be at increased risk of vascular disease. It is not known whether screening for vascular risk factors occurs in primary care. The aim of this study was to determine whether guidance advocating cardiovascular screening in RA patients is being implemented in primary care.

Methods

This study was undertaken in a UK primary care consultation database. All patients with a diagnosis of RA between 2000 and 2008, and still registered with the GP practice in 2009 were matched by age, gender and GP practice to three non-RA patients. Evidence of screening for five traditional vascular risk factors (blood pressure, lipids, glucose, weight, smoking) was compared in those with and without RA using logistic regression models. A comparison was also made with diabetes.

Results

401 RA patients were identified and matched to 1198 non-RA patients. No differences in the overall rates of screening were found (all five risk factors: RA 24.9% vs no RA 25.6%), but RA patients were more likely to have a smoking status recorded (67% versus 62%). In contrast, those with diabetes were up to 12 times as likely to receive vascular screening.

Conclusions

Despite the excess risk of vascular disease in patients with RA being of a similar magnitude to that seen in diabetes, patients with RA did not receive additional CVD screening in primary care, although this was achieved in patients with diabetes. More emphasis needs to be placed on ensuring those with RA are actively screened for cardiovascular disease in primary care.

Preventive services delivery in patients with chronic illnesses: parallel opportunities rather than competing obligations

PURPOSE

Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records.

METHODS

We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient's number of chronic conditions, adjusted for patient age and encounter frequency.

RESULTS

Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services.

CONCLUSIONS

Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.

Importance of Health Information Technology, Electronic Health Records, and Continuously Aggregating Data to Comparative Effectiveness Research and Learning Health Care

Rapidly accumulating clinical information can support cancer care and discovery. Future success depends on information management, access, use, and reuse. Electronic health records (EHRs) are highlighted as a critical component of evidence development and implementation, but to fully harness the potential of EHRs, they need to be more than electronic renderings of the traditional paper medical chart. Clinical informatics and structured accessible secure data captured through EHR systems provide mechanisms through which EHRs can facilitate comparative effectiveness research (CER). Use of large linked administrative databases to answer comparative questions is an early version of informatics-enabled CER familiar to oncologists. An updated version of informatics-enabled CER relies on EHR-derived structured data linked with supplemental information to provide patient-level information that can be aggregated and analyzed to support hypothesis generation, comparative assessment, and personalized care. As implementation of EHRs continues to expand, electronic databases containing information collected via EHRs will continuously aggregate; aggregating data enhanced with real-time analytics can provide point-of-care evidence to oncologists, tailored to patient-level characteristics. The system learns when clinical care informs research, and insights derived from research are reinvested in care. Challenges must be overcome, including interoperability, standardization, access, and development of real-time analytics.

Low frequency of primary lipid screening among medicare patients with rheumatoid arthritis

OBJECTIVE

Although studies have demonstrated suboptimal preventive care in RA patients, performance of primary lipid screening (i.e., testing before cardiovascular disease [CVD], CVD risk equivalents, or hyperlipidemia is evident) has not been systematically examined. The purpose of this study was to examine associations between primary lipid screening and visits to primary care providers (PCPs) and rheumatologists among a national sample of older RA patients.

METHODS

This retrospective cohort study examined a 5% Medicare sample that included 3,298 RA patients without baseline CVD, diabetes mellitus, or hyperlipidemia, who were considered eligible for primary lipid screening during the years 2004-2006. The outcome was probability of lipid screening by the relative frequency of primary care and rheumatology visits, or seeing a PCP at least once each year.

RESULTS

Primary lipid screening was performed in only 45% of RA patients. Overall, 65% of patients received both primary and rheumatology care, and 50% saw a rheumatologist as often as a PCP. Any primary care predicted more lipid screening than lone rheumatology care (26% [95% confidence interval (95% CI) 21-32]). As long as a PCP was involved, performance of lipid screening was similar regardless of the balance between primary and rheumatology visits (44-48% [95% CI 41-51]). Not seeing a PCP at least annually decreased screening by 22% (adjusted risk ratio 0.78 [95% CI 0.71-0.84]).

CONCLUSION

Primary lipid screening was performed in fewer than half of eligible RA patients, highlighting a key target for CVD risk reduction efforts. Annual visits to a PCP improved lipid screening, although performance remained poor (51%). Half of RA patients saw their rheumatologist as often or more often than they saw a PCP, illustrating the need to study optimal partnerships between PCPs and rheumatologists for screening patients for CVD risks.

The delivery of evidence-based preventive care for older Americans with arthritis

INTRODUCTION

Previous research suggests patients with rheumatoid arthritis (RA) may receive suboptimal care with respect to preventive tests and services. We evaluated the proportion of older Americans with RA, psoriatic arthritis (PsA), and osteoarthritis (OA) receiving these services and the specialty of the providers delivering this care.

METHODS

Using data from 1999 to 2006 from the Medicare Chronic Conditions Warehouse, we identified persons age >/= 65 in the national 5% sample. Over the required five-year observation period, we identified tests and services recommended for older adults and the associated healthcare provider. Services of interest included dual energy x-ray absorptiometry (DXA), influenza and pneumococcal vaccination, hyperlipidemia lab testing, mammography and colonoscopy.

RESULTS

After accounting for the sampling fraction, we identified 141,140 RA, 6,300 PsA, and 770,520 OA patients eligible for analysis. Over five years, a majority of RA, PsA, and OA patients were tested for hyperlipidemia (84%, 89% and 87% respectively) and received DXA (69%, 75%, and 52%). Only approximately one-third of arthritis patients received pneumococcal vaccination; 19% to 22% received influenza vaccination each year. Approximately 20% to 35% of arthritis patients never underwent mammography and colonoscopy over five years. Concomitant care from both a rheumatologist and a primary care physician was significantly associated with a greater likelihood of receiving almost all preventive tests and services.

CONCLUSIONS

Among older Americans on Medicare, the absolute proportion of persons with arthritis receiving various recommended preventive services and screening tests was substantially less than 100%. Improved co-management between primary care and arthritis physicians may in part improve the delivery of preventive care for arthritis patients, but novel systematic interventions in this area are needed.