The Impact of Rheumatoid Arthritis Co-morbidities
Rheumatoid arthritis (RA) is a chronic, disabling autoimmune disease which affects approximately 580,000 people in England. Around 80 per cent of these patients will have one or more co-morbidities, which means there are around 464,000 RA patients in England who have another long-term health condition.
The report presents evidence about the range of co-morbidities that RA patients are at risk of developing, including problems with eye, heart, lung and bone health, as well as the psychological impact of living with a long term condition. The report highlights the following types of co-morbidities as being particularly problematic:
- Cardiovascular disease: The risk of heart attack is doubled for RA patients. The risk of atrial fibrillation is around 40 per cent higher among RA patients than those without RA. The risk of stroke is 30 per cent higher for RA patients
- Interstitial lung disease: this disease associated with RA is a major cause of death amongst RA patients
- Osteoporosis: rates of osteoporosis can be up to twice as high amongst RA patients than the general population
- Cancer: leukaemia, lung cancer, lymphoma and multiple myeloma are all more common in people with RA
- Depression: rates of depression are raised amongst RA patients
Failure to manage these co-morbidities effectively will have a serious impact on the RA patient. For example, the presence of co-morbidities may add delays to the care pathway, and the co-morbidities themselves may increase the patient’s overall levels of disability, or even their risk of mortality.
Although current NICE guidelines recommend some checks for co-morbidities among RA patients10, the report finds that their implementation is patchy and the range of conditions for which checks are recommended is too limited.
The report goes on to recommend the introduction of a series of measures to improve awareness and effective management of co-morbidities by RA patients, healthcare professionals, commissioners and policymakers. If implemented in concert, we believe these measures will significantly enhance the patient journey while at the same time reducing the associated treatment costs to the NHS.
1. Providers should fully implement the recommendation in NICE Clinical Guideline 79 that all RA patients should be offered annual checks for co-morbidities and have access to a consultant-led multidisciplinary team
2. Providers should fully implement the Darzi recommendation that all people with long-term conditions should be given an annual personalised care plan, which is agreed with their healthcare professional
3. The Information Prescription for RA should be overhauled to include further information about the range of co-morbidities that affect people with the disease
4. The HQIP national clinical audit should make data available about the proportion of rheumatology teams that are offering care plans, conducting holistic annual reviews and co-morbidity assessments, and giving access to the full multidisciplinary team
5. The forthcoming Long-Term Conditions Outcomes Strategy should include a section on effective management of co-morbidities, which promotes investment in self-management programmes, annual care plans and holistic annual reviews to manage these risks
6. Additional outcomes strategies, including the forthcoming Cardiovascular Disease Outcomes Strategy, should include sections on effective management of co-morbidities and identify specific at risk populations, such as RA patients.
7. The forthcoming NICE Quality Standard for the management of RA should include a quality statement on the requirement to screen for co-morbidities and establish a care plan for every patient, and equivalent Commissioning Outcomes Framework indicators should be developed for all long-term conditions
8. The NHS Commissioning Board should establish a strategic clinical network for musculoskeletal conditions, which should advise clinical commissioning groups on the need to prioritise checks for co-morbidities, give access to multidisciplinary team services and assist with developing shared-care protocols
9. Future iterations of the Quality and Outcomes Framework should include a commitment for GPs to conduct holistic annual reviews with RA patients that screen for co-morbidities
10. The shortlisted early inflammatory arthritis best practice tariff for providers should be introduced as soon as possible and it should include an annual review as part of the configuration of the financial incentive