Background/Purpose: Patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular disease (CVD) as compared to the general population. The European League Against Rheumatism (EULAR) recommends that rheumatologists engage in assessing the CVD risks in RA patients. Multiple barriers such as limited time and lack of familiarity of CVD screening guidelines challenge the feasibility of this practice. Furthermore, recent data suggest that primary care providers fail to assess RA patients consistently or aggressively. At a tertiary referral center, we implemented an innovative system to provide RA patients direct access to cardiology for a CVD risk assessment. In the new RA-CVD clinic workflow, the rheumatologist can screen for CVD risk factors during a clinical visit and refer RA patients using a prescribed order set.  Next, the patient is evaluated by cardiology and the 10-year risk for atherosclerotic cardiovascular disease (ASCVD) score is calculated to help guide therapy decisions.  In this study, we examined patient access, lipid profiles and medication use before and after the intervention.

Methods: We devised an order set within the electronic medical record (EMR) that was available to all rheumatologists starting January 2015. The order set included a referral to the RA-CVD clinic, electrocardiogram, lipid profile or vertical auto profile (VAP), and hemoglobin A1C. For this study, we reviewed all RA patients presenting to our hospital for new or follow up appointments pre- and post- implementation of the program. Chart review was performed to identify elevated lipid profiles (LDL>130) and statin use.   Our cardiology team devised a specific protocol to best risk assess these patients per EULAR guidelines.

Results: Since the launch of our program, 722 RA patients have been seen by the rheumatology practice, 99 (14%) of these patients agreed and were then referred to the RA-CVD clinic. Screening for diabetes and hypercholesterolemia has improved by 60% with the implementation of the program.  To date, 13 patients have undergone full risk assessment, however not all patients have been seen partially due to cardiology appointment lag time.  Of these patients, 5/13 (38%) patients were started on a statin based on their ASCVD score.

Conclusion: Our study suggests that the creation of a RA-CVD workflow significantly increased the rates of risk factor screening and appeared to provide a forum for necessary interventions.   However, lack of cardiology access may limit the strength this program.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/advocating-for-rheumatoid-arthritis-and-cardiovascular-health-arch-in-a-tertiary-referral-center-a-collaborative-and-systems-based-approach-to-improve-access-to-care/