Recognizing CVD as the leading cause of death in RA, we sought to examine primary preventive screening for hyperlipidemia as a modifiable cardiac risk among RA patients in relationship to primary care and rheumatology outpatient visits. Overall, lipid testing occurred in fewer than half of all those eligible over three years. Patients with lone rheumatologic care had substantially less lipid screening when compared to patients with any primary care: 22% for lone rheumatologic care compared to 43–51% with other visit patterns that included at least some primary care. Those who saw a primary care provider at least once each year faired best with 51% testing. This finding was consistent with a study done in 2000 reporting lower routine cancer screening among RA patients without primary care contact, and a 2010 report examining multiple preventive services in RA (1
). However in our study, even with primary care involvement, observed rates of lipid screening remained poor regardless of visit proportions, suggesting a need to systematically improve preventive cardiovascular care for patients with RA.
We found that primary lipid screening for RA patients was significantly less frequent than reported rates in average ambulatory Medicare beneficiaries, estimated at 50–55% each year (36
). Our low observed screening performance also contrasts with the aforementioned 2010 RA study that reported 5-year lipid testing performance at 83.5% (26
). However that study did not separately examine primary versus secondary CVD risk screening populations or control for prevalent hyperlipidemia, CVD, or risk equivalents. Maintenance testing among secondary prevention populations, versus actual primary lipid screening, likely inflated observed rates in that study, though longer observation may have also influenced results. Performance in our primary prevention RA cohort was more analogous to screening in younger average-risk HMO populations whose three-year LDL testing was ~40% (37
). Our observed screening performance below general HMO and Medicare population rates suggest that RA patients were not receiving routine screening. This suggests possible impediments to routine care delivery, uncertainty regarding the complex relationship between lipids and CVD risk in RA (38
), or under-recognition of RA itself as a cardiovascular risk factor.
In our study, other predictors of poor lipid screening demonstrate opportunities to improve care for those who are older, sicker and have the fewest outpatient visits. Patients with more visits and a higher number of unique providers were more likely to be screened, consistent with a report citing that relevant specialist involvement may improve screening in complex patients (40
). Conversely, the finding of low screening among patients from large towns may reflect lower provider density, or smaller group practices that report lower quality than larger group practices (29
Universally, addressing the elevated CVD risk from inflammatory arthritis requires additional knowledge and vigilance to capture care delivery opportunities. In our sample, half of patients saw their rheumatologist at least as often as their PCP, and other reports suggest that rheumatology encounters often outnumber PCP visits (16
). Rheumatologists may feel that prevention is the role of primary care providers and may not want to interfere, even though they may be more familiar with CVD risk in RA. Primary care providers may be stretched to invoke disease specific prevention in limited encounters with patients also receiving specialty care. Coordinating the expertise of both the rheumatologist and primary care providers may be useful to improve preventive cardiovascular care.
Collaboration with specialists has been shown to improve the quality of preventive care for patients with complex conditions (41
); this collaboration may mitigate the common finding that patients with competing comorbidities often receive less preventive care than healthier patients (17
). One multi-specialty health network with a well-integrated electronic health record reported superior lipid and osteoporosis screening among patients with RA compared to the total network cohort, suggesting that optimal system support and multispecialty collaboration can enhance care delivery to complex populations (43
An optimal partnership between rheumatology and primary care to address cardiovascular risk has not been defined. Rheumatologists are familiar with RA disease-specific risks and could play a more active role in this process. Rheumatologists could educate patients and primary care clinicians regarding increased CVD risk in RA, or actively order screening, and/or co-manage modifiable risk factors. For instance, in contrast to low frequency lipid screening noted in our study, one academic rheumatology clinic that implemented routine screening practices reported 88% lipid testing at five years, highlighting the potential impact of specialty-driven protocols (44
). A pivotal parallel example of shifting prevention roles is the move in recent years to include osteoporosis within the relevant scope of specialty practice. Studies demonstrate that screening rates and treatment of routine and glucocorticoid-induced osteoporosis improve with rheumatologist collaboration (45
). Moreover, the 2010 study examining multiple evidence-based preventive services in RA showed that combined rheumatology and primary care predicted higher overall performance (26
). Our finding of improved lipid testing among those who saw a PCP at least once each year may suggest a role for rheumatologists to advocate annual PCP visits for RA patients.
Formal specialist roles have also been examined amidst the expanding dialogue regarding the “patient-centered medical home” (47
). The American College of Physicians (ACP) identifies rheumatologists caring for RA patients as a possible specialty-based medical home if first-contact, whole person, continuous, and integrated care is provided. However, the ACP Committee of Subspecialty Societies proposed an alternative specialist role as a “medical neighbor,” expanding the prior idea of a coordinated health system as a “medical neighborhood” (49
). As medical neighbors, specialists are not required to assume first-contact primary care responsibilities, but to promote co-management within the health system (47
). As such, rheumatologists may advocate annual PCP visits or co-manage cardiovascular prevention as good medical neighbors without assuming all primary care responsibilities. As research regarding the patient-centered medical home expands, and health systems increasingly assume responsibility for promoting health among populations, the role of specialists as medical neighbors for cardiovascular preventive care should be explored further.
As with any scientific analysis, this study has some limitations. First, there is the potential for misclassification of RA and other diagnoses. To address this concern, previously validated algorithms were used (1
). Though the strictest validation study used only rheumatologist-reported RA coding (19
) which demonstrated high correlation with audited ACR criteria, we adopted the convention of subsequent authors who used more than one RA code in 24 months (1
) to ensure including RA patients exclusively receiving primary care. Misclassification of osteoarthritis (OA) as RA may have occurred more frequently in the lone primary care group, but low screening rates appear consistent with rates among those receiving combined rheumatology and primary care suggesting that if OA patients were included it did not appear to have influenced observed screening. Second, there may be unmeasured differences between patients who see only a rheumatologist, such as patient preferences. We approached this concern by limiting our scope to primary prevention, stratifying and adjusting for a wide range of variables including number of visits, unique providers, overall comorbidity, and RA severity surrogates, though RA disease activity measures and treatments were not available. We found that the lone rheumatology group was least likely to receive orthopedic surgery or gait devices, suggesting that they did not have historically worse RA to justify lapsed screening. However, in the absence of acute disease activity measures or medications, we cannot exclude rational delays in screening given lipid fluctuations in patients with acute inflammation and steroid treatment (39
). We also acknowledge that ICD algorithms may underestimate hyperlipidemia if patients receive medications without coding the diagnosis. Quality measures recommend annual lipid testing among such secondary prevention patients even with statin treatment, so poor screening among potentially misclassified secondary risk patients on statins would reflect even more poorly. Third, the sample was limited to older adults with RA prior to 2006. It is unclear if our results are generalizable to younger patients or more recent years. However, it remains possible that with less comorbidity triggering health system contacts, younger RA patients may have even lower rates of lipid screening.
Finally, given that current RA-specific recommendations for CVD prevention are not explicit, and the exact role of lipids in CVD risk may be non-linear, our choice of a three-year versus five-year window for assessing lipid screening could be questioned (12
). However, it is unlikely that the poor observed screening rates would drastically improve by using a five-year window. As a simple exercise, if we consider our screening rate over three years, the inclusion of two more years boosts screening rates to 71% at best, still leaving more than one in four unscreened. Future work could examine a longer period, and should include a comprehensive assessment of all traditional CVD risk factors, as well as actual CVD outcomes.
In this primary CVD prevention cohort of RA patients, lipid screening was frequently overlooked. When examining visit patterns, as long as a primary care provider was involved, no significant difference in screening probabilities emerged regardless of the balance between primary and rheumatology specialty care. A 22% improvement in testing among those seeing a PCP at least once each year suggests a role for advocating annual PCP visits for patients with RA, though performance improved only to 51%. The remaining gap suggests that lapses in prevention may be one potential mechanism explaining why patients have not fully benefitted from declines in CVD seen in the general population despite aggressive RA treatment (3
). The observed gap in lipid screening highlights a key target for CVD risk reduction efforts. In addition, the finding that half of RA patients see their rheumatologist at least as often as primary care suggests a need to study optimal partnerships between primary care providers and specialists for screening CVD risk factors in high-risk populations within their medical homes and neighborhoods.