Inadequate cardiovascular disease risk factor (CVD-RF) screening

Rheumatoid arthritis (RA) is associated with an increased cardiovascular morbidity compared with the general population. Whether this also holds for cardiovascular mortality remains unclear.1–3 Although inflammation has been shown to contribute substantially to the development of cardiovascular diseases (CVDs) in patients with RA, there is also a high prevalence of traditional CVD-RFs among these patients.4–6 To reduce the risk of CVD in patients with RA, adequate cardiovascular risk management (CVRM) is necessary. In many (inter)national guidelines, adequate CVRM implies regular assessment, treatment and monitoring of CVD-RFs.7 8 The updated European League Against Rheumatism (EULAR) guideline recommends cardiovascular risk assessment at least once every 5 years.9 In the Netherlands, CVRM for patients with RA is also recommended in the Dutch College of General Practitioners’ guideline.10

An essential part of CVRM consists of screening of five traditional CVD-RFs: blood pressure, smoking status, body weight, blood glucose and lipid profile. Table 1 shows an overview of the studies that investigated the level of CVD-RF screening in patients with RA in general practices or outpatient clinics. In the literature, three types of reporting CVD-RF screening can be distinguished: screening of at least one CVD-RF,11–14 screening of all five CVD-RFs14–16 and screening of lipid levels only.17–19 Within these three categories, screening percentages vary between 24.9% and 69%. All studies indicated that CVD-RF screening in patients with RA is marginally applied in clinical practice, both in primary and secondary care. Reasons for insufficient CVD-RF screening in patients with RA are not fully clarified. Desai et al showed differences in registration or measurement methods of CVD-RFs between primary and secondary care.11 Another reason could be unawareness of RA as a risk factor for CVD by general practitioners (GPs).20 An intensive collaboration among GPs and between primary and secondary care could probably result in adequate CVD-RF screening.

This viewpoint describes the implementation of the EULAR CVRM guideline in patients with RA in a region in the South of the Netherlands where rheumatologists and GPs closely collaborate to manage the cardiovascular risk of patients with RA. Subsequently, the current performance of the collaboration of CVD-RF screening in a hospital-based RA population in this region is described.

Implementing the CVRM guideline in daily practice

In the region of Bernhoven (a hospital in the south of the Netherlands), primary and secondary care professionals work intensively together since 2013 to improve care for patients with chronic diseases.21 GPs in the neighbourhood of Bernhoven already collaborate in a GP association since 2007, named Synchroon care group. Together with the internal medicine specialists (ie, cardiologists and rheumatologists) of the hospital, GPs decided in 2013 to organise CVRM in the hospital surrounding region in a care programme especially for patients with an increased risk of CVD, including patients with RA. The tasks and responsibilities of the medical professionals working in primary and secondary care are arranged in regional transmural appointments. GPs receive reimbursement for the additional costs of CVRM from healthcare insurance companies.

Figure 1 illustrates the content of the CVRM care programme. Central concepts are self-management, an individualised care plan and one central caregiver (the GP). First step is the identification of patients with an increased risk of CVD and eligible for the CVRM care programme. Each GP has a list of patients with an increased CVD risk in their general practice; patients with newly diagnosed RA are added to this list. After identification, patients are invited for an appointment with the general practice-based nurse specialist, who screens the patients. If necessary, CVD-RFs are treated (pharmacologically or non-pharmacologically) and followed up in line with a personalised care plan.

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Figure 1

Collaboration between primary and secondary care to manage the cardiovascular risk of patients with rheumatoid arthritis. * Indications for referral are significant proteinuria, secondary/ maligne/ therapy resistant hypertension and familial hypercholesterolemia. ACE, angiotensin-converting-enzyme; BMI, body mass index; CVD, cardiovascular diseases; CVRM, cardiovascular risk management; FBG, fasting blood glucose; GP, general practitioner; HDL, high density lipoprotein; LDL, low density lipoprotein; RA, rheumatoid arthritis; RM, rheumatologist.

Quality control cycle

To check whether the collaboration between primary and secondary care works well, the percentage of patients with RA from the rheumatology department screened for CVD-RFs was investigated. Dyslipidaemia, as a risk factor, is frequently not assessed during CVD-RF screening.11 14 Therefore, we assumed that if a lipid profile was assessed, other traditional risk factors were also identified during the screening and therefore lipid testing was used as an indicator for CVD-RF screening. Lipid testing was stated as performed if LDL, HDL, cholesterol and triglyceride levels were all measured. All laboratory assessments from patients living in the Bernhoven region are performed in the same laboratory and presented in the electronic patient record of Bernhoven. For this study, we checked in November 2015 whether a lipid profile was assessed in the previous 5 years in all patients with RA of the outpatient clinic.

Data were extracted anonymised from the electronic patient record. The responsible medical ethical committee, CMO Arnhem Nijmegen, exempted this study from formal ethical approval. Descriptive statistics were used to describe data related to CVD-RF screening percentages. Potential differences between screened and non-screened patients with RA were tested by Student’s t-test (age), Mann-Whitney U test (disease duration) or χ² test (gender) using SPSS V.22.0.

In November 2015, 661 patients with RA were treated at the rheumatology outpatient clinic of Bernhoven. The mean age of these patients was 64±14 years (68% women) and disease duration was 7 (3–11) years (median (IQR)). Thirty-three patients with RA (5%) lived outside the Bernhoven region and were excluded subsequently from further analyses. In total, 628 patients with RA of the outpatient clinic were treated by 123 GPs of the Synchroon group with a median of four patients with RA per GP (IQR 1-18).

In 72% (454/628) of the patients with RA, a lipid profile was assessed in the previous 5 years. No difference in gender was found between the screened and non-screened patients (P=0.155). Screened patients were 11 years older compared with the non-screened patients (67 years (SD 11) vs 56 years (SD 15), P<0.0001) and had a longer disease duration (7 (4–12) (median (IQR)) vs 6 (2–9) years, P=0.003).

Interprofessional feedback

As part of interprofessional feedback, in February 2016, the GPs of non-screened patients with RA received a letter as a reminder for screening. Six months later, it was checked again whether lipid testing was performed.

Of the 174 (28%, 174/628) non-screened patients with RA, 100 had been screened after the reminding letter to their GP resulting in total screening of 88% (554/628) of all patients with RA. Main reasons, reported by GPs, why the remaining patients with RA were not screened (yet) were refusal by the patient, relocation of the patient, end state of life or other hospital’s medical specialist performs CVRM.

Collaboration as the success factor

The approach introduced in this viewpoint resulted in a CVD-RF screening percentage of 72%, which was improved to 88% by reminding the GPs to screen their patients with RA.

Potential key factors that probably contributed to this success:

• Due to the regional transmural agreements, medical professionals know their tasks and responsibilities in the CVRM care programme. The rheumatologist is responsible for initiating by informing the GP of each patient newly diagnosed with RA. The GP is responsible for screening, treatment and follow-up of CVD-RFs;

• Increased awareness of the increased risk of CVD in patients with RA;

• As laboratory results from all patients in the Bernhoven region are available in the electronic patient record system, a quality control loop of the CVD-RF screening could be performed;

• GPs receive financial compensation to perform CVRM in patients with an increased risk of CVDs from Dutch healthcare insurance companies.

Screening for CVD-RFs is the first step in reducing the elevated risk of CVD in patients with RA. After risk identification, appropriate treatment and follow-up are recommended in the updated EULAR guideline.9 After screening, established CVD-RFs should be treated adequately. A study of van den Oever et al showed suboptimal results for CVD-RF treatment.22 Further research is necessary to investigate whether the collaboration between rheumatologists and GPs also results in adequate management of CVD-RFs and ultimately less cardiovascular events in patients with RA. In addition, it will be interesting to investigate the feasibility and experiences with the use of non-invasive methods (ie, carotid ultrasound) for stratification of the cardiovascular risk in patients with RA, especially in primary care.

To conclude, the collaboration between primary and secondary care described in this viewpoint can be seen as good practice to provide care in line with the EULAR guideline.