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Rheumatoid arthritis
Original research
Utilisation of cardiovascular preventive services in a rheumatoid arthritis population-based cohort
  1. Daniel Montes1,
  2. Cassondra A Hulshizer2,
  3. Elena Myasoedova2,3,
  4. John M Davis III3,
  5. Andrew C Hanson2,
  6. Ali Duarte-Garcia3,
  7. Gabriel Figueroa-Parra3,
  8. Baptiste Chevet4 and
  9. Cynthia S Crowson2,3
  1. 1 Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2 Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
  3. 3 Division of Rheumatology, Mayo Clinic, Rochester, Minnesota, USA
  4. 4 Spécialité de Rhumatologie, Centre Hospitalier Universitaire de Brest, Brest, France
  1. Correspondence to Dr Cynthia S Crowson; crowson{at}mayo.edu

Abstract

Objectives The objective is to examine utilisation of cardiovascular preventive services in patients with rheumatoid arthritis (RA), compared with a non-RA population, and to examine cardiovascular disease (CVD) screening rates among RA patients without diabetes mellitus (DM), hypertension or hyperlipidaemia to non-RA patients with one of these diagnoses.

Methods All ≥18-year-old patients with an RA diagnosis living in one of eight Minnesota counties on 1 January 2015 were included and matched (1:1) by sex, age and county to non-RA comparators. Rates of screening for CVD risk factors, including DM (ie, glucose), hypertension (ie, blood pressure) and hyperlipidaemia (ie, lipids), were compared between groups using Cox models.

Results The study included 1614 patients with RA and 1599 non-RA comparators. DM screening was more common among patients with RA (HR: 1.10, 95% CI: 1.01 to 1.19), as was hypertension screening (HR: 1.37, 95% CI: 1.24 to 1.52). Hyperlipidaemia screening in RA was similar to comparators (HR: 0.99, 95% CI: 0.89 to 1.10). Conversely, patients with RA and no CVD risk factors had a lower probability of undergoing diabetes (HR: 0.67, 95% CI: 0.57 to 0.78) and hyperlipidaemia screening (HR: 0.65, 95% CI: 0.54 to 0.79) than non-RA patients with only one CVD risk factor diagnosis. Hypertension screening was similar between both groups.

Conclusions RA patients undergo CVD preventive screening at rates at least comparable to the general population. However, patients with RA as their sole CVD risk factor were less likely to undergo screenings, despite an equivalent-to-higher risk as the traditional CVD risk factors. These findings demonstrate opportunities for improvement of RA patient care.

  • Rheumatoid Arthritis
  • Cardiovascular Diseases
  • Hypertension

Data availability statement

Data are available upon reasonable request. Mayo Clinic Institutional Review Board (IRB) policy does not allow full access of patient information to be provided to a third party without prior approval from the IRB committee overseeing this study. However, access to the complete deidentified data can be made available following approval. Requests for additional study related data can be sent to CC at crowson@mayo.edu.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

http://dx.doi.org/10.1136/rmdopen-2023-003318

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Rheumatoid arthritis (RA) is recognised to cause an increased burden of cardiovascular disease (CVD) independent of traditional CVD risk factors and with a magnitude comparable to diabetes mellitus.

    • The total cardiovascular risk is additive between RA and the traditional CVD risk factors; thus, CVD preventive services are important in patients with RA to mitigate the risk.

    WHAT THIS STUDY ADDS

    • As of 2020, patients with RA presented different trends in CVD preventive services utilisation. Rates of diabetes and hypertension screenings were higher in patients with RA, while hyperlipidaemia screening was similar to comparators.

    • Among RA patients, those with a higher Charlson Comorbidity Index, smoking history, obesity, a shorter RA disease duration, recent use of disease-modifying antirheumatic drugs or who were diagnosed with RA at an older age were more likely to undergo at least two out of the three major CVD risk factor screenings (diabetes, hypertension, hyperlipidaemia). Socioeconomic factors including non-white race, education levels and Area Deprivation Index also showed some association with CVD risk factor screening.

    • Patients with RA as their sole CVD risk factor were significantly less likely to undergo diabetes or hyperlipidaemia screening, when compared with non-RA patients with only one traditional CVD risk factor diagnosis, despite the comparably higher CVD risk conferred by RA.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • Our results provide a contemporary survey of the utilisation of CVD preventive services among patients with RA. While there was a similar-to-higher utilisation of CVD preventive services for RA patients in general, CVD risk factor screening was not approached as aggressively in patients with RA as their sole CVD risk factor. This represents an opportunity for improvement.

    Introduction

    Rheumatoid arthritis (RA) is recognised to cause increased mortality due to an increased burden of cardiovascular disease (CVD).1 Systemic inflammation in RA is a key player in the pathogenesis of CVD independently of traditional risk factors such as hypertension, hyperlipidaemia or diabetes mellitus (DM).2–5 Furthermore, the total cardiovascular risk is additive between RA and traditional risk factors.6 7 Thus, in addition to adequate disease control, effective and optimal monitoring of CVD risk factors is an essential part of care for RA patients.

    As with the management of most chronic conditions, improvement and preservation of patient’s quality of life is an important goal in the treatment of patients with RA. In addition to effective disease control, early detection and mitigation of additional risk factors for potentially preventable conditions, such as CVD, are important considerations that can assist in achieving this goal.8 Furthermore, patients with RA and comorbid CVD were found to incur significantly higher follow-up costs compared with patients with RA alone.9 Currently, CVD risk factor screening with blood pressure measurements, lipoprotein profiles and fasting blood glucose is recommended at regular intervals to screen for hypertension, hyperlipidaemia and DM, respectively.10–12 Given the elevated CVD risk burden of RA patients, adherence to the recommended CVD risk factor screening schedules has the potential to improve patient’s quality of life and be cost-effective.

    CVD screening rates in patients with RA reported by previous studies, however, are variable. Due to continuously evolving screening practices, some of the previous studies may not reflect current practice, while other studies were based on claims data, which could lead to misclassification, or based at academic centres where the specialised setting could differ from the real-world community setting. With these considerations, we aimed to perform a contemporary assessment of the trends of CVD preventive service utilisation in patients with RA compared with non-RA comparators. Within this assessment, we also aimed to identify RA patient characteristics that may influence trends in preventive service utilisation. Lastly, we explored the effects of RA alone on CVD screening utilisation compared with patients without RA and only one traditional risk factor, hypothesising that patients with only one traditional risk factor would be screened more frequently than those with RA alone.

    Methods

    The Rochester Epidemiology Project (REP) allows ready access to the medical records for the local population from all healthcare providers, including institutions such as Mayo Clinic, Olmsted Medical Center, their affiliated hospitals, local nursing homes, etc. This system ensures a comprehensive ascertainment of preventive services provided among the residents of Olmsted, Dodge, Mower, Goodhue, Wabasha, Freeborn, Steele and Waseca counties.13 The demographics, distribution of morbidity and death rates in the REP region are like those in the Upper Midwest of the USA.13 The characteristics and strengths of the REP, as well as its generalisability, have been previously described, but briefly, the REP affords essentially complete information on the entire medical history of virtually all residents residing in the afore-mentioned eight-county region. This allows researchers to substantially eliminate sampling bias, as the REP captures the entire population.14 15 The following methodologies were in part adapted from a previously published population based study by our group.16

    Study population

    The complete inpatient and outpatient medical records for each potential case were manually reviewed by experienced nurse abstractors, and all incident patients fulfilled the 1987 American College of Rheumatology (ACR) classification criteria or the 2010 EULAR/ACR classification criteria for RA.17 Those who migrated to the eight-county region after diagnosis were included if they were prescribed disease-modifying antirheumatic drugs (DMARDs) and had a physician’s diagnosis of RA, when documentation of criteria fulfilment at the original diagnosis of RA was unavailable. We included all patients meeting the requirements described above who were at least 18 years of age and living in the eight-county region of Minnesota on 1 January 2015 (index date). Patients with RA were matched (1:1) on sex, age and county of residence to non-RA comparators. All patients with RA and non-RA comparators had at least 1 year of prior medical history and were followed until 29 February 2020, emigration out of the geographical area, or death. One year of prior medical history was required in order to appropriately assess whether patients fit the inclusion and exclusion criteria. The end date was selected as 29 February 2020 due to the beginning of restrictions on preventive services and non-emergency medical care secondary to the SARS-CoV-2 pandemic. Those without documented follow-up after 1 January 2015 were excluded from analyses.

    Data collection

    Through medical record review, we manually abstracted demographics, disease duration and clinical and serological RA features. Smoking status, DMARDs, hyperlipidaemia medications, antihypertensive use and glucocorticoid (GC) use were electronically retrieved from the patient medical record for RA and non-RA comparators for 5 years prior to the index date. The patients on GC therapy were then stratified by ≥90 days and <90 days of use. Obesity was defined as body mass index (BMI)≥30 kg/m2. Area Deprivation Index (ADI) national rankings at the census block group level were obtained using patient addresses.18 These variables were evaluated at index date. We used a 5-year lookback period prior to 1 January 2015 using International Classification of Diseases Ninth Revision (ICD-9) and ICD-10 diagnosis codes to identify the pre-existence of hypertension, hyperlipidaemia and DM. We also calculated the Deyo adaptation of the Charlson Comorbidity Index excluding the rheumatologic category.19

    Preventive service evaluation

    We evaluated DM, hypertension and hyperlipidaemia screening based on the US Preventive Services Task Force recommendations in effect during the 2015–2020 period.20–24

    As part of CVD screening, we evaluated hypertension screening in all subjects (excluding those with a history of hypertension) by documentation of a measurement of blood pressure.20 23 We also evaluated screening for hyperlipidaemia with the measurement of blood lipids in all patients (excluding those with treatments for hyperlipidaemia).21 22 DM screening was evaluated in all subjects≥40 years of age (excluding those with a history of DM) by assessing the measurement of blood glucose or haemoglobin A1C.24 The afore-mentioned measurements and tests were electronically retrieved using Current Procedural Terminology and laboratory codes.

    Statistical analysis

    Descriptive statistics were used to summarise the data. Chi-square and Wilcoxon rank-sum tests were performed to compare the baseline characteristics between patients with and without RA. The cumulative incidence of screening tests was estimated for patients with and without RA using Kaplan-Meier methods. Cox proportional hazards models with adjustment for age, sex and race were used to compare screening tests between the two groups. Additional adjustment for BMI and Charlson Comorbidity Index was also performed to account for differences between the RA and non-RA cohorts in some of the subgroup analyses. To assess how RA is approached as a CVD risk factor, we also created an RA-only subgroup that included all patients with RA who had no documented traditional CVD risk factor (diabetes, hypertension, hyperlipidaemia) diagnosis. This subgroup was compared against subgroups of non-RA patients with only one traditional CVD risk factor diagnosis. We then performed more stringent analyses, first by excluding patients with a prior CVD history (myocardial infarction, cerebrovascular disease, peripheral vascular disease), in both the RA-alone and non-RA groups. A third analysis did not exclude for CVD history, but included any smoking history as a CVD risk factor in both groups. A fourth analysis both excluded patients with prior CVD history and included any smoking history as a CVD risk factor in both groups. When analysing screening incidence, non-RA patients with the CVD risk factor in question were excluded from the subgroup being compared against the RA-only subgroup. To account for differences in patient characteristics when comparing these subgroups, inverse probability weighting was used to adjust for age, sex, BMI and Charlson Index. A p value of <0.05 was considered statistically significant for all analyses. Analyses were performed using SAS V.9.4 and R V.4.1.2 (R Foundation for Statistical Computing, Vienna, Austria).

    Results

    Baseline characteristics

    The study cohorts included 1650 patients with prevalent RA residing in the 8-county region on 1 January 2015 and 1650 non-RA comparators. Those with <1 year of prior medical history (16 RA patients, 30 controls) and those with no follow-up after 1 January 2015 (20 RA patients, 21 controls) were excluded. No patients were excluded for <19 years of age, as the age of patients ranged from 22 to 99 years. The resulting study population included 1614 patients with RA and 1599 non-RA comparators. The age, sex and racial/ethnic distribution were similar among both groups (table 1). We did not find any difference in BMI or ADI between the groups. A significantly larger percentage of RA patients were ever smokers than the comparators. Thyroid disease was more common among RA patients. RA patients also had a significantly greater mean Charlson Comorbidity Index than the comparators. In terms of prior CVD history, a similar proportion of RA patients experienced prior myocardial infarction and stroke compared with the non-RA comparators, but more commonly experienced prior peripheral vascular disease. For CVD risk factor history, hypertension was more frequent in RA patients than the comparators, and RA patients more commonly had documented use of antihypertensives. We did not find any differences in history of hyperlipidaemia or DM between patients with and without RA. GC use of any duration was significantly more frequent in RA patients than in comparators. Similarly, GC use ≥90 days total in 5 years before index was more frequent in RA patients than in comparators, although GC use <90 days total in 5 years before index was more frequent in the non-RA comparators than in RA patients. The use of lipid-lowering medications was similar between both groups (table 1).

    View this table:
    Table 1

    Demographic and baseline characteristics of patients with rheumatoid arthritis (RA) and matched non-RA comparators on 1 January 2015

    Patients with RA had a median disease duration of 6.5 years (IQR: 3.1–13.5). Either one or both rheumatoid factor and anticitrullinated peptide antibodies were present in 70.3% of patients with RA.

    CVD preventive services

    DM screening

    We included 1232 patients with RA and 1202 non-RA comparators as candidates for DM screening, after excluding those below the age of 40 and those with an established diagnosis of DM before 1 January 2015. By the end of the first year of follow-up, 60.8% of the patients with RA had been screened for DM, with a smaller proportion (55.9%) observed among the non-RA comparators. After 5-year follow-up, the adjusted cumulative screening rates showed that RA patients were 10% more likely to be screened for DM than their non-RA comparators (HR: 1.10, 95% CI: 1.01 to 1.19; table 2). Cumulative screening rates were recalculated after excluding patients with prior CVD history, and these yielded similar results for DM screening.

    View this table:
    Table 2

    Cumulative incidence rates of provided cardiovascular disease preventive services in patients with and without rheumatoid arthritis (RA)

    Among the RA patients eligible for DM screening, older patients (HR: 1.12, 95% CI: 1.07 to 1.17), patients with a smoking history (HR: 1.15, 95% CI: 1.02 to 1.29), patients with obesity (HR: 1.24, 95% CI: 1.09 to 1.40), patients with an RA duration of less than 5 years at the prevalence date (HR: 1.35, 95% CI: 1.17 to 1.57), patients who were diagnosed with RA at an older age (HR: 1.17 per 10-year increase, 95% CI: 1.08 to 1.27), patients with a Charlson Index Score≥2 (HR: 1.34, 95% CI: 1.18 to 1.52), patients who used GCs for ≥90 days in the 5-year period before the prevalence date (HR: 1.25, 95% CI: 1.10 to 1.41) and patients who used DMARDs in that 5-year period (HR: 1.40, 95% CI: 1.18 to 1.66) were more likely to undergo DM screening (table 3). Patients from neighbourhoods in the lowest quartile of the ADI (HR: 0.82, 95% CI: 0.69 to 0.97) were less likely to undergo DM screening.

    View this table:
    Table 3

    Association between patient characteristics and CVD preventive services in patients with RA

    Hypertension screening

    We included 744 RA patients and 849 non-RA comparators of all ages, as candidates for hypertension screening after excluding those with an established diagnosis of hypertension before 1 January 2015. By the end of the first-year follow-up, 81.3% of the patients with RA had received a blood pressure measurement, with a smaller proportion (71.8 %) observed among non-RA comparators (table 2). After 5-year follow-up, adjusting for age, sex and race, the cumulative screening rates showed that RA patients were 37% more likely to be screened for hypertension than their non-RA comparators (HR: 1.37, 95% CI: 1.24 to 1.52; table 2). Cumulative screening rates were recalculated after excluding patients with prior CVD history, and these yielded similar results for hypertension screening.

    Among the RA patients eligible for hypertension screening, the following patient subgroups were more likely to undergo screening for hypertension: patients with a smoking history (HR: 1.21, 95% CI: 1.04 to 1.40; table 3), patients with RA duration of less than 5 years at the prevalence date (HR: 1.22, 95% CI: 1.02 to 1.46), patients with a Charlson Index Score≥2 (HR: 1.55, 95% CI: 1.31 to 1.85) and patients who had used DMARDs in the 5-year period before the prevalence date (HR: 1.26, 95% CI: 1.02 to 1.56). Male patients with RA were less likely to undergo hypertension screening than female patients with RA (HR: 0.82, 95% CI: 0.69 to 0.98).

    Hyperlipidaemia screening

    We included 971 patients with RA and 945 non-RA comparators of all ages as candidates for hyperlipidaemia screening, after excluding for those with hyperlipidaemia-related prescriptions within 5 years prior to index. After 1-year follow-up, both RA and non-RA cohorts had similar proportions of patients undergo hyperlipidaemia screening (30.3% and 30.0%, respectively). After 5-year follow-up, the cumulative screening rates showed no difference between the RA and non-RA groups (HR: 0.99, 95% CI: 0.90 to 1.10). Cumulative screening rates were recalculated after excluding patients with prior CVD history, and these yielded similar results for hyperlipidaemia screening.

    Among the RA patients eligible for hyperlipidaemia screening, obese patients (HR: 1.42, 95% CI: 1.22 to 1.66), patients who were diagnosed with RA at an older age (HR: 1.15, 95% CI: 1.03 to 1.29) and patients with a Charlson Index Score≥2 (HR: 1.31, 95% CI: 1.11 to 1.56) were more likely to undergo hyperlipidaemia screening (table 3). Patients who were non-white were less likely to undergo this screening (HR: 0.74, 95% CI: 0.57 to 0.98). Socioeconomic factors, such as neighbourhoods in the lowest ADI quartile (HR: 1.21, 95% CI: 0.98 to 1.50), and patients with an education level beyond high school (HR: 1.18, 95% CI: 1.00 to 1.41) were also associated with hyperlipidaemia screening, but these associations did not reach statistical significance.

    How is RA approached as a CVD risk factor compared with the traditional CVD risk factors?

    To compare the prevalence of DM screening in RA versus traditional risk factors, we included 477 RA-only patients and 382 non-RA patients with either hypertension or hyperlipidaemia. For the comparison of hypertension screening, we included 579 RA-only patients and 160 non-RA patients with either hyperlipidaemia or DM. Lastly, for hyperlipidaemia screenings, we included 579 RA-only patients and 248 non-RA patients with either hypertension or DM. In these head-to-head comparisons, RA-only patients were 33% less likely to undergo DM screening compared with non-RA patients with one traditional risk factor (table 4). For hyperlipidaemia, RA-only patients were 35% less likely to undergo screening compared with the non-RA patients with only one traditional risk factor. However, RA-only patients had a similar likelihood to undergo screening for hypertension compared with the non-RA patients with only one risk factor.

    View this table:
    Table 4

    Utilisation of CVD preventive services by RA patients without CVD risk factors and non-RA comparators with one CVD risk factor

    After excluding prior CVD history from both groups, we obtained similar results, suggesting that patients with RA as their sole CVD risk factor were significantly less likely to undergo both DM and hyperlipidaemia screenings. When prior CVD history was not considered, but smoking was included as a traditional CVD risk factor, DM and hyperlipidaemia screenings appeared to occur less frequently in the RA-alone group compared with the non-RA with just one CVD risk factor group, but these differences did not reach statistical significance. Hypertension screening rates remained comparable between both groups. After excluding patients with prior CVD history and including smoking as a CVD risk factor, screenings for DM and hyperlipidaemia appeared to happen less frequently in the RA-alone group, but this again did not reach statistical significance. Hypertension screening rates remained comparable between both groups.

    Discussion

    The importance of implementing CVD preventive services in patients with RA is underscored by the 1.5–2.0-fold increased risk of developing coronary artery disease.25 26 In our study, we found that patients with RA were more likely to undergo DM and hypertension screenings but had no difference in likelihood of hyperlipidaemia screenings compared with the matched non-RA comparators. In a comparison between RA and the traditional CVD risk factors, the subgroup of RA patients with no documented traditional CVD risk factor diagnosis was 33% and 35% less likely to undergo DM and hyperlipidaemia screening, respectively, compared with non-RA patients with only one CVD risk factor diagnosis. Differences in screening between the RA-alone subgroup and the non-RA with just one CVD risk factor subgroup did not reach statistical significance after including smoking as a CVD risk factor and excluding for prior CVD history, although they continued to suggest lower DM and hyperlipidaemia screening rates in the RA-alone group.

    The incidence of CVD screenings in our general RA cohort is largely in agreement with other similar studies27–29 and shares a consistent pattern of hypertension screening having the highest incidence, followed by DM screening and, often more remotely, by hyperlipidaemia screenings. In terms of comparisons to the non-RA cohort, however, there is more variability, much of which can be explained by differences in endpoints, designs of the studies and patient population. A study from the UK by Monk et al found no significant differences in hypertension, DM or hyperlipidaemia screening incidence after 1 year, whereas our studies endpoints were examined after 5 years.29 They did note, however, that after the 1-year time frame, the RA cohort was 57% more likely to receive CVD screening of any kind. Another study within the Kaiser Permanente Health System reported that RA patients had 16.7, 2.31 and 1.25-fold greater likelihoods of hypertension, DM and lipid screening, respectively, compared with matched non-RA comparators.27 The differences reported in their study were considerably greater than those reported by us, but their RA cohort was focused on patients with cardiovascular comorbidities. Furthermore, they also noted an ongoing effort by their institution to achieve target clinical goals for CVD risk factor modification via more stringent monitoring.

    When comparing screenings between patients with RA as their sole CVD risk factor and non-RA patients with just one CVD risk factor, the existing literature is variable. Monk et al noted that patients with RA-alone underwent standard CVD screening at rates significantly less than DM only, hyperlipidaemia-only and hypertension-only patients.29 In contrast, An et al showed greater rates of CVD screening in their RA cohort.27 These inconsistencies are likely related to differences in study design, as the Monk’s study was limited by smaller sample sizes, and the An’s study did include patients with prior CVD. Also, unlike our study and the one by Monk et al, An et al did not examine RA as a CVD risk factor alone against the traditional CVD risk factors.

    Our data is similarly as mixed as the existing literature, though some items require closer consideration. Our initial matchup between the RA-alone group and the non-RA with just one CVD risk factor group did yield statistically significant results. In subsequent matchups which included smoking in our analyses, data continued to suggest lower screening rates for DM and hyperlipidaemia in the RA-alone group. Although the differences did not reach statistical significance, this can likely be attributed to drops in cumulative screening in the non-RA group, as cumulative screening in the RA-alone group remained fairly stable. The negative healthcare disparities that smokers experience are well documented,30 31 and thus it is possible that the disappearing significances may be driven by poor screening among smokers. Taken together, our data continue to suggest that CVD screening may not be approached as aggressively in patients with RA as the sole CVD risk factor, despite the equivalent-to-higher risk RA confers.

    The EULAR has recommended that patients with inflammatory joint disease (IJD) receive a CVD risk assessment every 5 years and that CVD risk factor models be adapted for patients with RA by using a 1.5 multiplication factor. Some European groups also evaluate for the presence of subclinical atherosclerotic disease in patients classified as low cardiovascular risk by the Systematic Coronary Risk Evaluation 10-year risk prediction model.32–34 Similar recommendations have not been made by equivalent American medical bodies, though they have acknowledged the additional CVD risk conferred by autoimmune conditions. American clinical practice could benefit from the establishment of similar recommendations, especially since our results show potential under-screening in patients with RA alone.

    Several RA patient characteristics were associated with CVD screening rates. A higher Charlson Comorbidity Index was significantly associated with all three screenings. Patients with more comorbidities have more clinic care,35 and this aligns with prior studies that have suggested that higher healthcare utilisation is associated with a higher incidence of CVD screening. Several characteristics were associated with a higher hazard for screening in two out of the three screens. Patients with a smoking history, an RA duration≤5 years or who had used DMARDs in the 5 years prior to incidence were more likely to undergo screenings for DM and hypertension. Patients with obesity and those who were diagnosed with RA at an older age were more likely to undergo screenings for DM and hyperlipidaemia. The effects of BMI and smoking were not unexpected, given that these represent traditional risk factors for CVD and would be expected to prompt clinicians for close surveillance. The effect of RA duration on screening hazard, however, is interesting. Patients who have lived with RA much longer may have stable regimens which are effective at controlling their disease activity. Conversely, those patients with a more recent diagnosis may still be in the process of titrating their regimen and thus have more clinically apparent disease activity, prompting clinicians to follow their CVD risk more closely. If this is the case, this practice would be in accordance with a report suggesting that disease duration does not independently influence CVD risk, but that disease activity over time may.2 Of note, RA duration did not influence hyperlipidaemia screening, and this may similarly be related to disease activity given the paradoxical lowering of lipids associated with high RA disease activity.6 This knowledge, however, is not widespread, and clinicians may therefore have a false sense of lipid control. The use of DMARDs in the 5 years prior to index could be cautiously interpreted as a proxy for disease activity, and this could explain the increased screening hazard in this patient group. However, patients who initiated a new DMARD in 2014 did not experience this increased likelihood, although notably this group of patients was much smaller in number. Interestingly, seropositivity did not influence screening rates, despite prior reports suggesting an association between the presence of rheumatoid factor or anticitrullinated peptide antibodies and cardiovascular events.36–38 Lastly, these subgroup analyses did shed light on possible socioeconomic disparities to be considered in this aspect of RA patient care. Patients who were non-white had consistently lower hazard ratios across the three traditional CVD screens, although only hyperlipidaemia screening reached statistical significance. This may be reflective of the generally lower access to healthcare non-white patients have in the USA. We also noted similar findings when considering patient education and ADI of place of residence.

    Our study had several strengths. First, the population-based design nested in the REP allowed us to depict the real state of RA care compared with the general population and reduced the risks of retrieval, reporting and recall biases. Furthermore, to our knowledge, our study is the first to report on the influence of disease duration on CVD risk factor screenings in RA patients. Limitations include our focus on screening practices without examination of management, such as diagnosis or achieving target clinical goals, which would give further insights into the quality of CVD risk factor modification in RA patients. Indeed, blood pressure measurement, for example, is often simply a part of clinic protocol, and obtaining a measurement may not always be done with a patient’s CVD risk in mind. Second, disease activity in RA is thought to be a large contributor to the excess CVD risk, but our study was not able to assess RA disease activity directly. Lastly, our study population may not be generalisable to other populations with more racial/ethnic diversity.

    Overall, patients with RA were demonstrated to undergo CVD risk factor screening at rates that were at least comparable to the general population. Existing CVD risk factors, such as obesity and smoking status, appear to increase the likelihood of CVD risk factor screening among RA patients. Clinically apparent disease activity may be prompting clinicians to closely surveil their patients’ CVD risk as those with shorter disease duration and who used DMARDs within the last 5 years had higher likelihood of screening. However, compared with non-RA patients with only one CVD risk factor, patients with RA as the sole CVD risk factor had a significantly lower likelihood to undergo CVD screening, suggesting that CVD risk factor screening may not be approached as aggressively in these patients despite the equivalent-to-higher risk burden. American clinical practice would benefit from the establishment of guidelines similar to the EULAR recommendations for CVD screening in IJD.

    Data availability statement

    Data are available upon reasonable request. Mayo Clinic Institutional Review Board (IRB) policy does not allow full access of patient information to be provided to a third party without prior approval from the IRB committee overseeing this study. However, access to the complete deidentified data can be made available following approval. Requests for additional study related data can be sent to CC at crowson@mayo.edu.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study was approved by the institutional review boards of Mayo Clinic (17-002593) and Olmsted Medical Center (017-OMC-17).

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    Footnotes

    • Twitter @MyasoedovaElena, @DrGabrielFP, @CrowsonCindy

    • Contributors Conceived and designed the study: DM, EM, JDM, AD-G, GF-P and CC. Collected the data: DM, CAH, EM, JMD, ACH, AD-G, GF-P, BC and CC. Analysed the data: CAH, ACH and CC. Wrote and revised the paper: DM, CAH, EM, JMD, ACH, AD-G, GF-P, BC and CC. Guarantor who accepts full responsibility for the work, had access ot the data and controlled the decision to publish: CC.

    • Funding This work was funded by grants from the National Institutes of Health, NIAMS (R01 AR46849) and NIA (R01 AG068192). This study used the resources of the Rochester Epidemiology Project (REP) medical records-linkage system, which is supported by the National Institute on Aging (NIA; AG 058738), by the Mayo Clinic Research Committee, and by fees paid annually by REP users. The content of this article is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health (NIH) or the Mayo Clinic.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.