Opportunities to Improve CVD Preventive Care for RA patients

TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE

Researchers have found a need for improving the process of identifying and treating risk factors for cardiovascular disease in patients with rheumatoid arthritis, according to findings published in Arthritis Care & Research.

“Although rheumatoid arthritis (RA) independently increases cardiovascular disease (CVD) risk, many RA patients receive suboptimal CVD preventive care,” wrote Christie M. Bartels, MD, MS, from the University of Wisconsin, Madison and colleagues. “We and others have reported disparities in lipid, diabetes mellitus, and hypertension care among RA patients compared to peers.”

In what the researchers believe is the first study examining patient, primary care physician (PCP), and rheumatologist perspectives of CVD preventive care in RA, 31 participants (15 patients, 7 rheumatologists, and 9 PCPs) participated in qualitative interviews that were coded using NVivo software and analyzed with grounded theory techniques.

The researchers found that while both patients and providers reported that CVD preventive care depends on identifying and acting on risk factors, most noted that both processes rarely occurred.

The researchers also found that while nearly half of PCPs and patients were unaware of CVD risk factors in RA, all rheumatologists were aware of these risk factors. However, rheumatologists often reported not systematically identifying risk factors, or described passing concerns about CVD risk factors to PCPs instead of acting directly, due to perceived role boundaries or due to a feeling of not having expertise in that area.

According to Dr Bartels and colleagues: “As one rheumatologist said, ‘To me there’s a reluctance, if I start a blood pressure pill in somebody whose blood pressure is 189/110… that’s really out of the scope of my practice.’” Other rheumatologists cited that poor knowledge of current CVD guidelines and vague RA-specific recommendations drove them to transfer concerns of CVD risks to PCPs.

The researchers also noted that while PCPs did not discuss concerns with role boundaries, some mentioned a difficulty in knowing specialty-specific recommendations.

Summary and Clinical Applicability

The researchers noted that understanding both the processes and barriers to delivering CVD preventive care is critical for improving care, reducing CVD, and increasing longevity for patients with RA.

“Our findings illustrate several opportunities for improving CVD preventive care delivery for RA patients. These include improved professional guidelines or recommendations to define action steps for CVD risk management in RA (similar to glucocorticoid-induced osteoporosis or immunization recommendations for rheumatologists), more explicit transfer practices, and system-based CVD preventive care,” the researchers wrote.

Limitations and Disclosures

The limitations of this study include that most of the observations came from a single US academic setting, even though 9 primary care groups, 3 rheumatology group practices, and a neighboring health maintenance organization were included. The patient sample was also generally insured, educated, and all English-speaking. However, the researchers noted that their findings still provide a framework for discussion, and argue that the poor performance in this group most likely reflects poor performances in other populations.

Reference

Bartels CM, Roberts TJ, Hansen KE, et al. Rheumatologist and Primary Care Management of Cardiovascular Disease Risk in Rheumatoid Arthritis: Patient and Provider Perspectives. Arthritis Care Res. 2016; doi:10.1002/acr.22689.