Background/Purpose:

Studies have shown patients with rheumatoid arthritis (RA), a chronic inflammatory condition, have accelerated rate of coronary artery and cerebrovascular disease. Patients with RA, in particular women, are at a higher risk for silent MI. In addition to treating the underlying RA, aggressive monitoring and treatment of traditional risk factors must be addressed.

At our federally qualified health center (FQHC), as primary care physicians, while we may not prescribe biologics for our RA patients, we should focus on the traditional risk factors associated with cardiovascular disease (CVD). This performance improvement project was to examine if we as primary care physicians (PCP) at the FQHC, at the minimum, are addressing traditional modifiable risk factors for CVD in our RA patients.

Methods:

A retrospective chart review was performed. Patients were identified using clinic encounters with an associated ICD9 code for rheumatoid arthritis (714.0) in the EMR at our FQHC, from January 1, 2014 through December 31, 2014. Charts were searched to see if traditional risk factors for CVD according to the Framingham Heart Study were measured and/or addressed in 2014. They include age, diabetes mellitus (DM), smoking, systolic blood pressure, total cholesterol, HDL, and BMI. Charts were also reviewed for documentation of smoking cessation and weight loss and lifestyle changes in patients with BMI greater than 25. The BMI was identified in one of the four categories, underweight (<18.5), healthy weight (18.5-24.9), overweight (25-29.9) and obese (>30).

Results:

A total of 78 subjects were identified. 14 were male and 64 were female. Mean age was 52 years. Of the 78 patients, 57% had their lipid profile examined and 42% did not. 17% of the RA patients had DM, of whom 79% were on anti-diabetes agent and 21% were not treated. In evaluating BMI in RA patients, 14% were healthy weight, 41% were overweight and 45% were obese. Of those who were overweight or obese, 70% had their BMI addressed and 30% did not. 26% of RA patients were smokers and of those 50% were educated regarding smoking cessation. 10% of the RA patients had documented uncontrolled hypertension either with or without anti-hypertensive agent.

Conclusion:

At FQHC as PCP, while we may not prescribe biologics to treat RA, we should at the minimum address the other modifiable risk factors such as hyperlipidemia, uncontrolled SBP, increased BMI and smoking for our RA patients. Currently, we are suboptimal at focusing in all of these factors. US Preventive Service Task Force recommends patients at higher risk for CVD, the age to begin screening lipid disorder is age 20.  At our FQHC, it is only being tested 57% of the time and slightly above two thirds of the overweight or obese RA patients are being advised regarding weight loss and lifestyle modifications. Only half of the smokers were educated and informed regarding smoking cessation. 

American Heart Association recognizes rheumatoid arthritis as a risk factor for atherosclerosis and increased risk of CVD. At FQHC, we need better adherence to ACR and AHA guidelines and goals of RA disease management. This may be achieved through interventions such as physician education, and use of clinical reminders in the FQHC, both of which are underway at this time.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/determining-the-rate-of-cardiovascular-risk-assessment-in-patients-with-rheumatoid-arthritis-at-federally-qualified-outpatient-continuity-clinic-a-performance-improvement-project/