Quality of care for patients with rheumatoid arthritis

Context Patients with rheumatoid arthritis are at risk for substantial morb idity because of their arthritis and premature mortality due to comorbid di seases. However, little is known about the quality of the health care that these patients receive. Objective To assess the quality of the health care that rheumatoid arthriti s patients receive for their arthritis, comorbid diseases, and health care maintenance and to determine the effect of patterns of specialty care on qu ality. Design, Setting, and Participants Historical cohort study of 1355 adult rhe umatoid arthritis patients en rolled in the fee-for-service or discounted f ee-for-service plans of a nationwide US insurance company, Patients were id entified and followed up through administrative data between 1991 and 1995. Main Outcome Measures Quality scores for arthritis, comorbid disease, and h ealth care maintenance were developed from performance on explicit process measures that related to each of these domains and described the percentage of indicated health care processes performed within each domain during eac h person-year of the study. Results During 4598 person-years of follow-up, quality scores were 62% (95% confidence interval [CI], 61%-64%) for arthritis care, 52% (95% CI, 49%-55 %) for comorbid disease care, and 42% (95% CI, 40%-43%) for health care mai ntenance. Across domains, care patterns including relevant specialists yiel ded performance scores 30% to 187% higher than those that did not (P<.001) and 45% to 67% of person-years were associated with patterns of care that d id not include a relevant specialist. Presence of primary care without spec ialty care yielded health care maintenance scores that were 43% higher than those for patterns that included neither primary nor relevant specialty ca re (P<.001). Conclusions In this population, health care quality appears to be suboptima l for arthritis, comorbid disease, and health care maintenance. Patterns of care that included relevant specialists were associated with substantially higher quality across all domains. Patterns that included generalists were associated with substantially higher quality health care maintenance than patterns that included neither a generalist nor a relevant specialist. The optimal roles of primary care physicians and specialists in the care of pat ients with complex conditions should be reassessed.