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Efforts Needed to Improve Quality of Care for Rheumatoid Arthritis Patients:
Study Suggests Contact with Relevant Specialist Physician Associated with Higher Quality of Care

CHICAGO -- 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 (JAMA).

Catherine H. MacLean, MD, PhD, of the University of California, Los Angeles, and colleagues studied 1,355 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 three areas by measuring performance in specific processes of health care.

According to background information cited in the article, rheumatoid arthritis is a chronic disabling condition that affects about 1 percent 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 coexisting, or 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.

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 percent of the time for arthritis care during each person-year compared with 52 percent and 42 percent of the time for comorbid disease care and health care maintenance, respectively," the authors write. "Overall, across all domains, 57 percent 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 percent to 187 percent 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 health care maintenance domain, patients who had contacts with a primary care physician, but no relevant specialist, had performance scores 43 percent higher than patients who had contact with neither.

"Our findings provide support to those who have recently called for re-evaluation 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.

This work was supported by an Arthritis Foundation Postdoctoral Fellowship Award to Dr. MacLean, the support of UCLA STAR Program for Dr. MacLean, the VA Ambulatory Care Fellowship program for Dr. MacLean, and by a grant from the UCLA Multipurpose Arthritis and Musculoskeletal Diseases Center.

(JAMA. 2000; 284:984-992)

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For more information about The Journal of the American Medical Association or to obtain a copy of the study, please contact the American Medical Association's Science News Department at (312) 464-5374.