Rheumatologists may be well aware of the increased risk for cardiovascular disease (CVD) among patients with rheumatoid arthritis (RA), but a recent study suggests that they may be focusing on the rheumatic problem while passing the cardiovascular one to primary care providers (PCPs), who too often are failing to pick up the ball.
According to a retrospective cohort study conducted among patients at the University of Michigan, PCPs were significantly better than rheumatologists at identifying and managing obesity, high blood pressure, and elevated lipids in RA patients. But even they had more success among patients with diabetes, whose risk level is similar, than among RA patients.
The researchers compared records of patients at a tertiary care center who were matched for age, gender and ethnicity and divided into three groups of 251 subjects each: patients with RA, those with diabetes mellitus, and people without either disease who were being seen for other problems. Most of the patients were Caucasian women; the mean age was 49. Researchers reviewed electronic patient records from a continuous 12-month period (June 2007 through April 2011) to see how well rheumatologists and PCPs managed CVD risk factors.
In overweight and obese patients, a subgroup analysis found that PCPs managed weight in 31% of those with RA, 68% of those with diabetes, and 46% of unaffected patients. PCPs also identified and managed smoking status, lipid levels and fasting blood glucose more frequently in RA patients than did rheumatologists.
Rheumatologists identified elevated BMI in 27% of patients with RA and helped only 6% to achieve weight reductions. They identified smoking status in only 21% and managed it in 13%. The rheumatologists did somewhat better at identifying high blood pressure, which they reported correctly in 93% of the hypertensive RA patients. But they achieved the necessary reductions in only 6%. They identified elevated lipids in just 6% of affected RA patients and resolved the problem in only 2%..
The authors speculate that many rheumatologists overlook cardiovascular issues in their RA patients, assuming (correctly or otherwise) that the PCP is taking care of that. But according to these findings RA patients do not benefit from the same vigilance for CVD risk factors in primary care that is offered for patients who have diabetes.
Better coordination of care is needed, the authors suggest, and perhaps more aggressive management of cardiovascular risk by the doctors who see RA patients most often.