Background/Purpose

Cardiovascular disease is the leading cause of mortality in the rheumatoid arthritis (RA) population. However, cardiovascular risk factors such as hyperlipidemia are undertreated in patients with RA compared to other high risk groups like diabetics. We examined the effectiveness of two interventions to increase screening for hyperlipidemia among patients with RA within the rheumatology practice of an academic medical center.

Methods

Interventions included a web-based survey regarding attitudes towards lipid screening in patients with RA sent to physicians in the division of rheumatology at the University of Pennsylvania on 1/6/14 and posters and flyers about cardiovascular risk in inflammatory arthritis posted in each clinic’s check-in area and exam rooms between 2/1-2/28/14. A query of our electronic health record was used to generate a list of patient visits with an ICD-9 code for RA seen in the practice between 7/1/13 – 4/15/14. Charts were reviewed for a random sample of 100 patient visits for the periods before and after the interventions (7/1 – 1/5/14 and 2/1 – 4/15/14 respectively). Patients were excluded if the rheumatologist had not documented a diagnosis of RA in the encounter note. If multiple visits for the same patient were found in the sample, the last visit in that period was used. The outcome was achieved if lipid screening was documented as performed in the encounter note or if results were recorded in the encounter note or in the laboratory section within 3 years of the visit date. The prevalence of up to date lipid screening in each period was assessed, and the groups were compared using the chi-squared test.

Results

Seventy-eight patients in the pre-intervention group and 82 in the post-intervention group satisfied inclusion criteria. Demographics are listed in the Table. Lipid screening was considered up to date in 39 of the 78 patients (50.0%) in the pre-intervention group and 57 out of the 82 patients (69.5 %) in the post-intervention group (p=0.01).

Conclusion

Among patients with RA, the management of traditional cardiovascular risk factors, including lipid screening, is suboptimal. Flyers and posters increased the prevalence of documented lipid screening in the short term. The survey of physician attitudes towards lipid screening likely also increased awareness of practice patterns among rheumatologists. Further quality improvement initiatives are needed to identify long term solutions to improve the recognition and management of traditional cardiovascular risk factors among patients with RA.  

Table. Demographics of the Pre and Post Intervention Groups

		Before N= 78	After N=82
Practice	Presbyterian Medical Center	15	24
	Perelman Center	61	51
	Fellows’ Clinic	2	7
Age- Median (Range)		60 (27-89)	60 (32-87)
Gender	Female	63 (81%)	74 (90%)
Primary Care Physician Location	Outside of the University of Pennsylvania System	53 (68%)	44 (53%)
Diabetes		12 (15%)	16 (20%)
Disease Activity	Not Recorded	4	7
	Remission	23	23
	Low	18	27
	Moderate	24	20
	High	9	5
Lipid Lowering Drugs Used	Statin	22	23
	Fish oil/ Omega-3-acid ethyl esters	12	9
	Flaxseed oil	2	1
	Ezetimibe	1	1
	Fenofibrate	1	1
Service Ordering Lipid Screening	Primary Care	19	35
	Rheumatology	11	17
	Cardiology	6	2
	Endocrine	0	2
	Inpatient Medicine	0	1
	Oncology	1	0
	Renal	1	0
	Not Clear	1	0

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/improving-screening-for-hyperlipidemia-in-patients-with-rheumatoid-arthritis-at-an-academic-rheumatology-practice/