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Quality of Care for Patients With Rheumatoid Arthritis
Catherine H. MacLean, MD, PhD;
Rachel Louie, MS;
Barbara Leake, PhD;
Daniel F. McCaffrey, PhD;
Harold E. Paulus, MD;
Robert H. Brook, MD, ScD;
Paul G. Shekelle, MD, PhD
JAMA. 2000;284:984-992.
Context Patients with rheumatoid arthritis are at risk for substantial morbidity because of their arthritis and premature mortality due to comorbid diseases. 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 arthritis patients receive for their arthritis, comorbid diseases, and health care maintenance and to determine the effect of patterns of specialty care on quality.
Design, Setting, and Participants Historical cohort study of 1355 adult rheumatoid arthritis patients enrolled in the fee-for-service or discounted fee-for-service plans of a nationwide US insurance company. Patients were identified and followed up through administrative data between 1991 and 1995.
Main Outcome Measures Quality scores for arthritis, comorbid disease, and health 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 each 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 maintenance. Across domains, care patterns including relevant specialists yielded 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 did not include a relevant specialist. Presence of primary care without specialty care yielded health care maintenance scores that were 43% higher than those for patterns that included neither primary nor relevant specialty care (P<.001).
Conclusions In this population, health care quality appears to be suboptimal 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 patients with complex conditions should be reassessed.
Author Affiliations: Department of Medicine (Drs MacLean, Paulus, and Brook), School of Public Health (Drs MacLean, Leake, and Brook), and School of Nursing (Dr Leake), University of California, Los Angeles; RAND Health Program, Santa Monica, Calif (Drs MacLean, McCaffrey, Brook, Shekelle, and Ms Louie); Greater Los Angeles VA Health Care System and Veterans Affairs Health Services Research and Development Service, Los Angeles, Calif (Dr Shekelle).
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