If you have rheumatoid arthritis, use the following quality measurements to work with your doctor to find the best treatment for your disease.
Time to Referral
If you have been referred to a physician for a new diagnosis of rheumatoid arthritis, then that doctor should see you within three months.
History and Exam
Within three months of your diagnosis and at appropriate time intervals thereafter, the doctor should document the following in your chart:
a joint exam of three or more joint areas,
your ability to function in your daily life,
the progression and activity of your disease,
your inflammation level measured by an ESP or CRP (sed rate) blood test and
your pain level.
Regular Follow-Up
A physician should evaluate the progress of your rheumatoid arthritis annually.
Radiographs (X-rays) of the Hands and Feet
Your doctor should take baseline X-rays of your hands or feet within three months of your diagnosis of rheumatoid arthritis and every 3 years.
Radiographs (X-rays) of the Cervical Spine
If you have rheumatoid arthritis and are having surgery requiring general anesthesia, there should be management or documentation of the risk of instability of the first and second cervical vertebrae, which can cause compression of the spinal cord or brain stem.
DMARDS
If you have a definite diagnosis of rheumatoid arthritis as determined by a sero-positive test result, evidence of active disease or X-rays showing joint erosion, your doctor should prescribe a disease-modifying, anti-rheumatic drug (DMARD) unless there is a reason you can not take it.
If you have a definite diagnosis of rheumatoid arthritis and are taking a DMARD and your symptoms have worsened over a six-month period and there is continued evidence of disease activity, then your doctor should do one of the following:
Change your dose or method of administration of the DMARD,
Prescribe a different DMARD,
Prescribe an additional DMARD or
Start or increase the dosage of glucocorticoids.
Folic Acid
If you are taking methotrexate, your doctor should also prescribe a folate supplement to help reduce the side effects of methotrexate such as stomach and intestinal disturbances and hair loss.
Osteoporosis Prevention
If you are taking 10 or more milligrams of prednisone or another steroid daily for more than three months, your doctor should also prescribe 1,500 mg of calcium, 400 i.u. of vitamin D daily to prevent osteoporosis. Your doctor should also discuss osteoporosis-preventing drug therapy with you.
If you have osteoporosis in addition to your rheumatoid arthritis and you are taking oral or parenteral steroids, then your doctor should prescribe osteoporosis drugs to try to prevent further progession.
Glucocorticoids
If you have been taking more than 10 milligrams of prednisone or another steroid daily for more than six months without any signs of worsening disease activity, then your doctor should attempt to taper off your steroid dosage and increase your DMARD dosage.
Exercise
If you have rheumatoid arthritis and are able to safely exercise, your doctor should prescribe a directed or supervised muscle strengthening or aerobic exercise program and should review it with you at least once a year.
Assistive Devices
If you are having difficulty walking because of stiffness, pain or instability resulting from your rheumatoid arthritis, then your doctor should evaluate you for assistive devices such as a cane, insoles or orthotics.
Likewise, if you begin having difficulty with tasks of daily living like brushing your teeth or dressing, or have trouble using your hands and wrists, your doctor or a therapist should evaluate you for assistive devices that can help you with the tasks you are having difficulty completing and for hand or wrist splints.
Surgery
If you have severe pain in your hips or knees that significantly limits your activities despite any drug and non-drug therapies, your doctor should refer you to an orthopaedic surgeon, unless you are not a candidate for surgery.
If you have joint pain, instability or tendon rupture affecting your upper extremity, foot or ankle to the point where it significantly limits your activities despite any drug or non-drug therapies, then your doctor should refer you to a surgeon, unless you are not a candidate for surgery.
Baseline and Follow-up Studies
If you are taking a newly prescribed DMARD, then your doctor should conduct the appropriate baseline studies and document the results soon after you begin taking the prescription so the effectiveness of the drug can be determined and monitored appropriately.
If you are taking a DMARD or glucocorticoids, then your doctor should be monitoring you for drug toxicity.
Methotrexate and Liver Enzyme Levels
If you are taking methotrexate and have elevated liver enzyme levels in your blood two or more times over three months, then your doctor should reduce or discontinue your NSAID or methotrexate within one month of the second elevated test result to reduce the risk of liver problems.
Informing Patients About Risks
When your doctor prescribes a drug, whether it is NSAIDs, DMARDs, acetaminophen, glucocorticoids or narcotics, then he or she should discuss the risks versus the benefits of the drug therapy with you and this discussion should be documented in your chart.
Reproductive Issues
If you are a woman of child-bearing age and your doctor wants you to begin taking a DMARD such as methotrexate, cyclophosphamide, azathioprine, sulfasalazine, chlorambucil, D-penicillamine, hydroxychloroquine, gold, etanercept, infliximab, or leflunomide, he or she needs to discuss with you the risks these drugs can have on a fetus (i.e., birth defects) and proper contraception choices.
If you are pregnant, do not take methotrexate or leflunomide. If you are in your third trimester of pregnancy, do not use NSAIDs or aspirin.
Vaccines
If you are on immunosuppressants and/or steroid therapy, you should not be given the live/oral polio, live typhoid, yellow fever, MMR or BCG vaccine.
If you are immunosuppressive therapy, then you need to have had the following vaccines: influenza (annually), pneumococcal, meningococcal, haemophilus B, hepatitis B and tetanus.
Source: MacLean CH, Saag KG, Solomon DH, Morton SC, Sampsel S, Klippel JH. Measuring quality in arthritis care: Methods for developing the Arthritis Foundation's quality indicator set. Arthritis Care and Research 2004; 51: 193-202.
http://ww2.arthritis.org/conditions/qualityindicators/quality_indicators_ra.asp
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