Reducing Time to Treatment in Patients with Early and Uncontrolled RA: Implementation of a Collaborative and Systems-Based Approach to Improve Access to Care.

Background/Purpose: The first three months following the onset of the first symptoms of rheumatoid arthritis (RA) represent a therapeutic window during which disease-modifying anti-rheumatic drug (DMARD) treatments have been shown to provide disease remission and limit subsequent joint damage. In established RA, the goal of treatment is to achieve minimal disease activity (MDA) as it is associated with less articular and non-articular complications from RA. Delays between symptom onset and the initiation of therapy persist due to multifactorial issues: patient delays in seeking medical advice, primary care physician’s (PCP) delays in recognizing symptoms and referring the patient to a rheumatologist, and delays in accessing rheumatology care. While some PCPs are able to recognize early RA (ERA) and start a DMARD, MDA may not be achieved. These factors also delay evaluation by a rheumatologist and potentially cause further damage.

The aim of this study was to decrease the time from first onset of RA symptoms of to rheumatology evaluation and DMARD treatment. If the patient had been prescribed a DMARD by the PCP, the goal was to decrease the time to step-up therapy in those RA patients who were not in the MDA state.

Methods: This 24-month outcomes study using descriptive analysis, focused on improving patient outcomes through enhanced community partnerships, systems-based change and education. Key components of the project’s success were the incorporation of a dedicated nurse practitioner, acting as the division’s patient case manager, and a medical assistant (MA) who served as a patient navigator to coordinate care. These patients were then prioritized by need and seen by a provider or rheumatology nurse practitioner ( NP) who is specifically trained in evaluating and treating patients with RA.

Four primary care clinics serving diverse patient populations were selected as partners for this study. A needs assessment was performed in the partner clinics to assess baseline knowledge related to the diagnosis and treatment of RA. Subsequently, targeted education related to ERA treatment and the importance of achieving MDA was created and offered to the partner clinics throughout the duration of the study.

Results:

From January, 2017 to May, 2018, 1794 unique patients were referred to our Rheumatology clinic. Of these, 106 were diagnosed with RA while 83 were defined as ERA. Of these RA patients, there were 65 (61%) that were not being treated with DMARD therapy prior to evaluation. The time from referral to evaluation by rheumatology declined significantly  from an average of 103 days at baseline to 27 days in the final phase of the study (graph 1). Accordingly, the time between referral to the initiation of DMARD therapy decreased significantly.

Conclusion: This study suggests that the creation of a specific workflow to assess patients with ERA or uncontrolled RA significantly combined with targeted education improved the wait time to a rheumatology evaluation and time to treatment. Our findings are limited by our hospital’s status as a tertiary medical center.