Efforts Needed to Improve Quality of Care

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Efforts Needed to Improve Quality of Care for Rheumatoid Arthritis Patients

August 23, 2000

JAMA/MedscapeWire

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The quality of care for patients with rheumatoid arthritis falls far short of

recommended guidelines, although patients who had contact with relevant

specialist physicians received higher quality care, according to an article in

the August 23/30 issue of The Journal of the American Medical Association.

H. MacLean, MD, PhD, of the University of California, Los Angeles, and

colleagues studied 1355 adults with rheumatoid arthritis who were enrolled in

fee-for-service or discounted fee-for-service plans of a nationwide insurance

company from 1991 to 1995. The researchers wanted to assess the quality of care

the patients received for arthritis, for other coexisting diseases, and for

health maintenance. They determined quality scores for all 3 areas by measuring

performance in specific processes of healthcare.

The researchers report that overall, the quality of care for the patients they

studied was below the optimal level. " We found that quality of care for

rheumatoid arthritis patients, as assessed by a number of process measures, fell

far short of recommended guidelines and varied as a function of both health care

domain and pattern of specialty care, " they write.

Patients generally received higher quality care for arthritis than for

prevention or for treatment of coexisting diseases. " Recommended processes were

performed, on average, 62% of the time for arthritis care during each

person-year compared with 52% and 42% of the time for comorbid disease care and

health care maintenance, respectively, " the authors write. " Overall, across all

domains, 57% of recommended care was performed. "

Patients who had contact with specialists received substantially higher quality

care. " Within each of the domains, subjects that had relevant specialist

contacts had performance scores that were 30% to 187% higher than those who did

not, " the authors write.

They point out that this finding is particularly noteworthy, since nearly half

the patients in the study never saw a specialist.

Performance scores in the arthritis and comorbid disease domains were slightly

higher for patients who had contacts with a primary care physician, but no

relevant specialist, compared with patients who had contact with neither,

although the differences were not statistically significant. In the healthcare

maintenance domain, patients who had contacts with a primary care physician, but

no relevant specialist, had performance scores 43% higher than patients who had

contact with neither.

" Our findings provide support to those who have recently called for reevaluation

of the optimal roles of generalists and specialists in the care of patients with

complex conditions. Health care delivery models that use primary care physicians

as overseers for overall care may not be the best models for patients with

rheumatoid arthritis if primary care physicians restrict access to specialty

care, " the authors assert.

" Efforts are needed to improve the quality of care for rheumatoid arthritis

patients and to increase physician awareness of comorbid diseases among patients

with this chronic disease, " they conclude.

According to background information cited in the article, rheumatoid arthritis

is a chronic disabling condition that affects about 1% of American adults. It is

associated with a 5- to 15-year reduction in life expectancy. Early death stems

not from the arthritis itself, but rather from comorbid diseases that commonly

affect the general population - including diabetes mellitus, heart disease, and

gastrointestinal bleeding. Patients with rheumatoid arthritis are at increased

risk for these conditions as a consequence of the arthritis itself and from the

drugs used to treat it.

JAMA. 2000;284:984-992

http://rheumatology.medscape.com/MedscapeWire/2000/0800/medwire.0823.Efforts.htm\

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