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Clinical audit suggestions: rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory disease which largely affects synovial joints. RA typically affects the small joints of the hands and the feet, and usually both sides equally and symmetrically, although any synovial joint can be affected. It is a systemic disease and so can affect the whole body, including the heart, lungs and eyes. There are approximately 400,000 people with RA in the UK. The incidence of the condition is low, with around 1.5 men and 3.6 women developing RA per 10,000 people per year. This translates into approximately 12,000 people developing RA per year in the UK.

Standards

National Institute for Health and Care Excellence (NICE) guidelines [CG79] Rheumatoid arthritis in adults: management

The British Society for Rheumatology (BSR) and British Health Professionals in Rheumatology (BHPR) guideline for the management of rheumatoid arthritis (after two years) (PDF, 985 kb)

Quality and Outcomes Framework (QOF) menu indicators for RA (NM55, NM56, NM57, NM58):

  • The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritis.
  • the percentage of patients with rheumatoid arthritis aged 30–84 years who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 15 months
  • the percentage of patients aged 50–90 years with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 27 months
  • the percentage of patients with rheumatoid arthritis who have had a face-to-face annual review in the preceding 15 months.

Audit criteria

Audit performance against NICE CG79 using the audit support tool developed to support the implementation of NICE guidance. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations.

People with autoimmune diseases such as RA and also those receiving immunosuppressive treatments for their disease are at increased risk of respiratory infections and related complications. Therefore all patients with RA should be offered immunisation against influenza and pneumococcus.

Patients with RA have an increased risk of cardiovascular events, similar to patients with type II diabetes. Remember that patients with high inflammatory markers carry an increased risk of cardiovascular disease. Many deaths in RA are caused by cardiovascular events driven by inflammatory components of their disease. Therefore, as well as assessment of CVD risk using a CVD risk assessment tool adjusted for RA, all patients with RA should have the following documented in their patient notes and be offered appropriate interventions to reduce their CVD risk:

  • measurement of BP
  • measurement of fasting lipids
  • measurement of glucose
  • weight and BMI
  • waist measurement
  • advice around physical activity and exercise
  • smoking cessation advice.

Patients with RA have a high incidence of depression. Therefore all patients with RA should be screened for depression using a validated tool e.g. ultra-short screening tool, Patient Health Questionnaire (PHQ-9) or the Hospital Anxiety and Depression Scale (HADS).

Resources

Read code: N040 rheumatoid arthritis 

FRAX: WHO fracture risk assessment tool This risk assessment tool is adjusted for RA.

QFracture-2012 10-year fragility fracture risk, adjusted for RA

QRISK2-2012 cardiovascular disease risk calculator This CVD risk assessment tool is adjusted for RA to work out the risk of having a heart attack or stroke over the next 10 years. It is suitable for people who do not already have a diagnosis of heart disease or stroke.

NICE guidelines [CG127] Hypertension in adults: diagnosis and management

NICE guidelines [CG181] Cardiovascular disease: risk assessment and reduction, including lipid modification

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