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Ensuring Quality Care for RA

by Robert S. Dinsmoor

If you have rheumatoid arthritis (RA), you want to be sure that your doctor is giving you quality care. But how do you know what that is? The management of individuals with RA is complicated, and advances in the understanding and treatment of RA in the past decade have made it more so. Even some physicians may be unsure of the “state of the art” for treating RA.

To address that concern and create a standard for assessing treatment, both the American College of Rheumatology (ACR) and the Arthritis Foundation (AF) have come up with quality measurements, or indicators. The quality measurements aren’t meant to dictate to doctors exactly what they should be doing when they treat people with RA — sometimes a doctor may decide to do things differently because doing so fits a particular individual’s needs better. But they’re a way for interested groups, such as doctors themselves, researchers, policy makers, and consumers, to assess the care people with RA are getting.

For you, the consumer, becoming familiar with the quality measurements will help you understand why the doctor’s questions about your RA are so important, what kinds of information the doctor needs you to report back on, how the doctor evaluates the progress of RA, and the type of care you should be getting. If reading this article leaves you with questions about your care, talk to your doctor. The doctor should be willing to explain any differences in approach and to work with you to make sure you get the care you need and deserve.

The quality measurements for RA developed by the AF and the ACR are very similar, although the AF measurements look at more aspects of care than the ACR measurements currently do. Because this makes the AF measurements more useful for the consumer, the article mainly describes them. When it comes to drug safety, however, the ACR’s quality measurements have more to say, and this is reflected in the section on monitoring for possible side effects.

Evaluating RA

We now know that RA can damage the joints very early on and that certain drugs can prevent or slow the damage. For these reasons, the consensus among doctors and researchers is that RA should be diagnosed early and treated early. The AF’s first quality measurement says that individuals referred to a physician for a new diagnosis of RA should see that physician as soon as possible — within three months of the referral. (Often it is a general practitioner, suspecting RA, who will refer an individual to a rheumatologist, a doctor who specializes in diagnosing and treating arthritis and other musculoskeletal disorders. It is especially important to see a rheumatologist if your family doctor is unsure about the proper diagnosis and treatment of RA.) Within three months of diagnosis, and at least once a year after that, the doctor should do the evaluation described below.

The doctor should examine at least three of your joints. In a joint exam, the doctor may check for swelling or nodules in your joints. The doctor will also evaluate your joints’ range of motion.

The doctor should try to pin down how active your RA is and how it is progressing. The joint examination will help with this. So will your answers to the doctor’s questions about your symptoms. When are your symptoms at their worst? For how long does your morning stiffness last? How much pain do you have? Do you frequently feel tired? Think about your symptoms before you go to the doctor and be prepared to answer questions about them.

The doctor should also assess how your arthritis affects your day-to-day functioning. How easy is it for you to walk up or down stairs? Can you reach items on a high shelf? Are you able to tie your shoes? To help your doctor collect this information, you may be asked to complete a Health Assessment Questionnaire (HAQ), which measures what impact RA has on your daily ability to function. (You’ll find an example of a HAQ on the Stanford University Web site.)

The doctor should order a blood test to check the amount of inflammation you have. This will be either an erythrocyte sedimentation rate (ESR, or “sed rate”) test or a C-reactive protein (CRP) test.

You should have x-rays of the hands and feet early on, as these joints are often involved in RA. Taken early in the course of RA, x-rays may not show any damage to the bone, but these early x-rays are helpful as a “baseline” reading. Doctors will compare them with x-rays taken later on to determine whether RA has caused bones to thin or erode or whether the “joint space” — the space between bones in a joint — has narrowed, indicating a loss of cartilage. You should have repeat x-rays of the hands and feet every three years. (When it comes to x-rays, another AF quality recommendation says that people with RA should have x-rays of the first and second cervical vertebrae, at the top of the spine, before any surgery requiring general anesthesia. If these vertebrae are affected by RA, they can become unstable. If they are unstable, the surgeon needs to know ahead of time for your safety’s sake.)

Last Reviewed on July 9, 2010

Robert S. Dinsmoor is a medical writer and editor based in Massachusetts.

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