Professor Robert Moots (left) and Dr Ashar Ahmed highlight the opportunities and challenges presented by the NICE quality standard for rheumatoid arthritis
R heumatoid arthritis (RA) is an inflammatory disease that usually affects the small joints of the hands and feet, although any joint can be affected. It is a systemic disease that can impact on the whole body, including the cardiovascular system, lungs, heart, eyes, and small blood vessels. If sub-optimally treated, RA can lead not only to joint destruction with associated morbidity and disability (see Figure 1), but also premature mortality. It imposes a significant economic burden, with total UK costs, including indirect costs and work-related disability, estimated at around £2.4 billion per year.1
In recent years, two approaches to addressing the many problems associated with RA have led to major advances in therapy and outcomes:
- early diagnosis and treatment—clinical research has shown the importance of early diagnosis and treatment of RA, within a so-called ‘window of opportunity’, where dynamic therapy, started soon after onset of the disease, can lead to much more effective disease suppression and improved outcomes2,3
- new drug therapies—laboratory research into the pathophysiological mechanisms underlying this serious disease has led to the development of new and effective targeted therapeutic agents, typified by the ‘biologic drugs’.
The outlook for an individual developing RA today is far better than in the past. If RA is diagnosed early, and treated promptly and effectively, there is a high probability of inducing and maintaining full remission, or at least low disease activity, with excellent long-term outcomes.4
NICE quality standards
NICE has published a rolling programme of quality standards for a variety of disease and topic areas. A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements within a particular area of care. These statements are intended as aspirational but achievable markers of high-quality patient care, covering the treatment and prevention of specific conditions. They are, importantly, cost effective as well as evidence based. Using NICE guidance and other NICE-accredited evidence sources, the quality standards encompass:
- clinical effectiveness
- patient safety and experience.
The Health and Social Care Act (2012) makes it clear that in discharging its duty, NHS England/the Secretary of State ‘must have regard to the quality standards prepared by NICE’.5 The standards help demonstrate the delivery of high-quality care through measurable outcomes and indicators that may be used in a variety of ways, for example in:
- the quality and outcomes framework (QOF)6
- the Clinical Commissioning Group Outcomes Indicator Set (CCGOIS)7
- the Commissioning for Quality and Innovation (CQUIN) Initiatives8
- national audit and data collection
- local audits and local contracts.
Quality standard for rheumatoid arthritis
A number of technologies and strategies for treating RA have received detailed appraisal and assessment by NICE, and many have been found to be both clinically and cost effective for the NHS. So if there has been a revolution in the management of RA, with the expectation of remission, and if the strategies to achieve this are well known and fully approved, why is there a need for a NICE quality standard on this condition?
The answer is that there remains much variability in the understanding of and approach to the management of RA in the UK. This may become even more pronounced with recent changes in the funding and commissioning of medical services in the UK. What services should be commissioned, and what level of care is appropriate? The NICE Quality Standard (QS) 33 for rheumatoid arthritis (in adults aged 16 years and older) (see www.nice.org.uk/qs33) has been published within the context of these important questions. 1
Development of the standard
The Topic Expert Group (chaired by one of the authors of this article) for NICE QS331 comprised key professionals and stakeholders, including:
- nurses and allied health professionals involved in the care of RA
- a primary care physician with a special interest in musculoskeletal disease
- a commissioner
- patient group representatives.
The group met on three occasions to consider evidence-based best practice for the management of RA, with a special focus on NICE Clinical Guideline (CG) 79 on Rheumatoid arthritis: the management of rheumatoid arthritis in adults (see www.nice.org.uk/CG79).9 This process led to the development of seven quality statements (see Table 1).
How will the quality standard improve patient care?
NICE QS331 was devised to inform best evidence-based practice and commissioning for RA. Importantly, the standard spans both primary and secondary care, since the optimal management of RA requires a successful partnership between the GP, specialist team, and the patient. The quality standard should be considered alongside other policy documents that are relevant to RA (e.g. the musculoskeletal services framework10).
|1||People with suspected persistent synovitis affecting the small joints of the hands or feet, or more than one joint, are referred to a rheumatology service within 3 working days of presentation.|
|2||People with suspected persistent synovitis are assessed in a rheumatology service within 3 weeks of referral.|
|3||People with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.|
|4||People with rheumatoid arthritis are offered educational and self-management activities within 1 month of diagnosis.|
|5||People who have active rheumatoid arthritis are offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.|
|6||People with rheumatoid arthritis and disease flares or possible drug related side-effects receive advice within 1 working day of contacting the rheumatology service.|
|7||People with rheumatoid arthritis have a comprehensive annual review that is coordinated by the rheumatology service.|
|NICE (2013) QS33. Quality standard for rheumatoid arthritis. Available at: publications.nice.org.uk/quality-standard-for-rheumatoid-arthritis-qs33/list-of-quality-statements Reproduced with permission.|
Early assessment and treatment—statements 1–3
One of the key advances in the management of RA has been to identify the benefits of effective treatment early on, before joint damage occurs, with the aim of preventing this damage. Statement 1 of NICE QS331 promotes early referral of a patient presenting with persistent synovitis (affecting the small joints of the hands or feet, or more than one joint) to the rheumatology specialist team. Indeed this must occur very quickly—no later than 3 working days after presentation (statement 1). Following assessment by the rheumatology team, which should occur within 3 weeks of referral (statement 2), definitive treatment with disease-modifying anti-rheumatic drugs (DMARDs) should be commenced, all within just 6 weeks of the initial patient referral (statement 3). Achieving these time-frames will be a challenge in itself, but optimal early and effective therapy will bring with it considerable benefits for patients, including:
- reduced disability, co-morbidity, and need for surgery
- enhanced ability to work
- improved quality of life.
Later management and review—statements 4–7
The importance of appropriately experienced multidisciplinary teams (comprising nurse specialists, physiotherapists, occupational therapists, podiatrists, and orthotists, under the leadership of the rheumatologist) is highlighted consistently throughout the standard.1 Multidisciplinary teams are essential for providing the many other elements known to improve outcomes in RA, for example:
- education about disease and therapy (statement 4)
- ability to escalate therapy at monthly intervals, as required (statement 5)
- rapid response to patient concerns and flares of disease (statement 6)
- comprehensive annual review (statement 7)—annual review is important in performing a holistic assessment of the many different aspects of RA and its associated co-morbidities (e.g. cardiovascular disease, osteoporosis) in order to improve health.
Although the standards in NICE QS331 are certainly achievable, there is no doubt that they will present a challenge from many angles, in both primary and secondary care. First, there is the onus on GPs to refer patients with suspected RA to specialist services very early on, as soon as 3 working days after consideration of RA (or earlier). Equally, there will be pressure on rheumatology services to review, definitively diagnose, and institute appropriate therapy for patients within 6 weeks of referral. Whilst most hospitals have multidisciplinary team rheumatology units, not all will have the full complement of clinicians required. Having to respond promptly to patients’ queries, ensure rapid access to services, appropriate education, and a yearly review, may challenge even well-staffed units, prompting a reorganisation of priorities.
Rheumatoid arthritis is most effectively managed through an active collaboration between primary and secondary care. It is important to realise that the role of the GP does not end after the diagnosis and referral of a patient with suspected RA. The rheumatologist works with the patient and the GP to develop a treatment plan. Primary care has an important role in monitoring the patient after DMARD therapy is started. The role of the GP in the management of a patient with RA includes:
- obtaining regular laboratory tests
- monitoring for infections
- minimising the risk of infections by ensuring that patients receive appropriate vaccination, such as those for pneumonia, influenza, and hepatitis B
- monitoring for malignancies.
However challenging it may be to meet the requirements of NICE QS33, it must be remembered that the quality standard is evidence-based, will deliver cost effectiveness, and will clearly bring benefits to patients, who will receive optimal quality of care for what would otherwise continue to be a miserable, costly, and potentially disabling condition.
- The NICE quality standard for RA should stimulate an early review of services currently commissioned against the statements to identify areas where action is needed
- Local commissioners and specialist providers should consider education programmes for primary care clinicians to ensure they are aware of the quality standard and can accurately identify synovitis
- Commissioners should consider, with their colleagues in public health, publicity campaigns (e.g. in pharmacies) for patients to present early with symptoms of synovitis to their GPs (again to avoid delay in diagnosis)
- Commissioners should agree local care pathways for referral of patients with synovitis that include investigations which should be performed at the time of referral (or soon after) to facilitate speedy diagnosis
- CCGs will need to agree with secondary care, formularies for biologic agents as these drugs are excluded from the Payment by Results tariff and will be prescribed by specialists, yet the cost will fall to CCGs as â€˜pass-through drugsâ€™
- CCGs will also need to agree and fund shared-care pathways for primary care to prescribe drugs that are initiated by specialists but which require regular monitoring in primary care (e.g. methotrexate, azathioprine) using local enhanced services
- CCGs could audit against the pathway by identifying patients with new diagnoses of RA and checking their diagnostic and treatment history against the standard
- Tariff costs for rheumatology outpatients: £217 (new), £100 (follow up).a
RA=rheumatoid arthritis; CCG=clinical commissioning group
- NICE website. Rheumatoid arthritis. Quality standard 33. www.nice.org.uk/qs33 (acccessed 16 July 2013).
- van Nies J, Krabben A, Schoones J et al. What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? A systematic literature review. Ann Rheum Dis 2013; Apr 9 [Epub ahead of print].
- Gülfe A, Kristensen L, Geborek P. Six and 12 weeks treatment response predicts continuation of tumor necrosis factor blockade in rheumatoid arthritis: an observational cohort study from southern Sweden. J Rheumatol 2009; 36 (3): 517–521.
- Aletaha D, Funovits J, Keystone E, Smolen J. Disease activity early in the course of treatment predicts response to therapy after one year in rheumatoid arthritis patients. Arthritis Rheum 2007; 56 (10): 3226–3235.
- Legislation.gov.uk website. Health and Social Care Act 2012, s 2. Available at: www.legislation.gov.uk/ukpga/2012/7/contents/enacted (accessed 16 July 2013).
- British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2013/14. London: BMA, NHS Employers, 2013. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/qof-2013-14.pdf
- NHS England. The CCG outcomes indicator set 2013/2014. NHS England, 2012. Available at: www.england.nhs.uk/wp-content/uploads/2012/12/ois-ataglance.pdf
- NHS Institute for Innovation and Improvement website. Commissioning for Quality and Innovation (CQUIN) payment framework.www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
- NICE. Rheumatoid arthritis: the management of rheumatoid arthritis in adults. Clinical Guideline 79. London: NICE, 2009. Available at: www.nice.org.uk/CG79
- Department of Health. The musculoskeletal services framework. London: DH, 2006. webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/Publicationsandstatistics/Publications/
- Choy E, Taylor P, McAuliffe S et al. Variation in the use of biologics in the management of rheumatoid arthritis across the UK. Curr Med Res Opin 2012; 28 (10): 1733–1741. G