Abstract:Objective
Despite increased cardiovascular disease (CVD) risk, rheumatoid arthritis (RA) patients often lack CVD preventive care. We examined CVD preventive care processes from RA patient and provider perspectives to develop a process map to identify targets for future interventions to improve CVD preventive care.
Methods
Thirty-one participants (15 patients, 7 rheumatologists, 9 primary care physicians (PCPs)) participated in interviews, which were coded using NVivo software and analyzed using grounded theo… Show more
“…Far from optimal, these findings might be explained by rheumatologists’ perceived limited role in preventive care. In our prior qualitative interviews, some rheumatologists reported being less likely to identify or manage CVD risk factors (e.g., hypertension, smoking) due to the perception that this is the role of primary care physicians [16]. …”
Background
Among patients with rheumatoid arthritis (RA), smoking increases risk for severe RA and pulmonary and cardiovascular disease (CVD). Despite this, little is known about smoking cessation counseling by rheumatologists.
Objectives
We examined predictors of tobacco counseling in RA patients who smoke including the effect of perceived RA control. We hypothesized that patients with controlled RA would receive more counseling according to the competing demands model, which explains that preventive care gaps occur as a result of competing provider, patient, and clinic factors.
Methods
This secondary data analysis involved RA patients with an additional CVD risk factor identified in an academic medical center 2004–2011. Trained abstractors assessed documented smoking counseling and rheumatologists’ impression of RA control in clinic notes. We used multivariable logistic regression to predict having received smoking cessation counseling, including sociodemographics and comorbidity in models.
Results
We abstracted 3,396 RA visits, including 360 visits (10%) with active smokers. Perceived controlled RA was present in 31% of visits involving smokers (39% in non-smokers). Beyond nurse documentation, providers documented smoking status in 39% of visit notes with smokers, and smoking cessation counseling in 10%. Visits with controlled versus active RA were less likely to include counseling (OR 0.3, CI 0.1–0.97). Counseling was more likely in visits with prevalent cardiovascular, pulmonary, and psychiatric disease, but decreased with obesity.
Conclusions
Smoking cessation counseling was documented in 10% of visits and was less likely when RA was controlled. Given smoking’s impact on RA and long-term outcomes, systematic cessation counseling efforts are needed.
“…Far from optimal, these findings might be explained by rheumatologists’ perceived limited role in preventive care. In our prior qualitative interviews, some rheumatologists reported being less likely to identify or manage CVD risk factors (e.g., hypertension, smoking) due to the perception that this is the role of primary care physicians [16]. …”
Background
Among patients with rheumatoid arthritis (RA), smoking increases risk for severe RA and pulmonary and cardiovascular disease (CVD). Despite this, little is known about smoking cessation counseling by rheumatologists.
Objectives
We examined predictors of tobacco counseling in RA patients who smoke including the effect of perceived RA control. We hypothesized that patients with controlled RA would receive more counseling according to the competing demands model, which explains that preventive care gaps occur as a result of competing provider, patient, and clinic factors.
Methods
This secondary data analysis involved RA patients with an additional CVD risk factor identified in an academic medical center 2004–2011. Trained abstractors assessed documented smoking counseling and rheumatologists’ impression of RA control in clinic notes. We used multivariable logistic regression to predict having received smoking cessation counseling, including sociodemographics and comorbidity in models.
Results
We abstracted 3,396 RA visits, including 360 visits (10%) with active smokers. Perceived controlled RA was present in 31% of visits involving smokers (39% in non-smokers). Beyond nurse documentation, providers documented smoking status in 39% of visit notes with smokers, and smoking cessation counseling in 10%. Visits with controlled versus active RA were less likely to include counseling (OR 0.3, CI 0.1–0.97). Counseling was more likely in visits with prevalent cardiovascular, pulmonary, and psychiatric disease, but decreased with obesity.
Conclusions
Smoking cessation counseling was documented in 10% of visits and was less likely when RA was controlled. Given smoking’s impact on RA and long-term outcomes, systematic cessation counseling efforts are needed.
“…Disagreements were rectified by a third reviewer (CMB) who also oversaw the coding scheme. The coding scheme was informed by prior qualitative work on cardiovascular prevention and clinic‐based care delivery from rheumatology patient and provider interviews and new codes based on current participant data. A detailed summary of the coding scheme is available in , available on the Arthritis Care & Research web site at http://onlinelibrary.wiley.com/doi/10.1002/acr.23858/abstract.…”
Section: Methodsmentioning
confidence: 99%
“…Although many forms of inflammatory arthritis, including ankylosing spondylitis and psoriatic arthritis, are also associated with an increased risk of CVD, associations between smoking, CVD, RA, and SLE have been studied extensively and may be more profound . We therefore focused on RA and SLE, building upon our prior work with these populations .Patients with rheumatoid arthritis and systemic lupus erythematosus reported that better understanding the negative effects of smoking on rheumatic disease and its treatment would motivate them to quit smoking.Patients who smoke requested point‐of‐care advice in rheumatology clinics on smoking cessation strategies and connections to cessation resources like tobacco quitlines, a free resource in all states.Emphasizing the rheumatology‐specific why and the resource‐specific how of smoking cessation is important when designing and evaluating smoking cessation interventions for use in rheumatology clinics.…”
Objective
Although smoking is a risk factor for cardiovascular and rheumatic disease severity, only 10% of rheumatology visits document cessation counseling. After implementing a rheumatology clinic protocol that increased tobacco quitline referrals 20‐fold, we undertook this study to examine patients’ barriers and facilitators to smoking cessation based on prior rheumatology experiences, to solicit reactions to the new cessation protocol, and to identify patient‐centered outcomes or signs of cessation progress following improved care.
Methods
We recruited 19 patients who smoke (12 with rheumatoid arthritis [RA] and 7 with systemic lupus erythematosus [SLE]) to participate in 1 of 3 semistructured focus groups. Transcripts of the focus group discussions were analyzed using thematic analysis to classify barriers, facilitators, and signs of cessation progress.
Results
Participant‐reported barriers and facilitators to cessation involved psychological, health‐related, and social and economic factors, as well as health care messaging and resources. Commonly discussed barriers included viewing smoking as a crutch amid rheumatic disease, rarely receiving cessation counseling in rheumatology clinics, and very limited awareness that smoking can worsen rheumatic diseases or reduce efficacy of some rheumatic disease medications. Participants endorsed our cessation protocol with rheumatology‐specific education and accessible resources, such as a quitline. Beyond quitting, participants prioritized knowing why and how to quit as signs of progress outcomes.
Conclusion
Focus groups identified themes and categories of facilitators/barriers to smoking cessation at the levels of patient and health system. Two key outcomes of improving cessation care for patients with RA and SLE were knowing why and how to quit. Emphasizing rheumatologic health benefits and cessation resources is essential when designing and evaluating rheumatology smoking cessation interventions.
“…An often debated aspect of CVD risk management has been whether this care should be the domain of the primary care physician (PCP) or the rheumatologist [42, 43]. EULAR recommendations from 2009 and 2017 emphasize that rheumatologists should be responsible for CVD risk management in RA.…”
Section: Introductionmentioning
confidence: 99%
“…We and others have noted gaps in screening for diabetes mellitus [42, 49], and a lack of lifestyle counseling [47, 101]. Reasons for this are likely multifactorial, including lack of time, perhaps lack of knowledge or experience, or a belief that this is managed in primary care [42]. The updated 2017 EULAR recommendations advocate lifestyle counselling, emphasizing the importance of these strategies for overall health.…”
The increase in cardiovascular disease (CVD) risk in rheumatoid arthritis (RA) is well known; however, appropriate management of this elevated risk in rheumatology clinics is less clear.
Purpose of Review
By critically reviewing literature published within the past five years, we aim to clarify current knowledge and gaps regarding CVD risk management in RA.
Recent Findings
We examine recent guidelines, recommendations, and evidence, and discuss three approaches: (1) RA-specific management including treat-to-target and medication management, (2) assessment of comprehensive individual risk, and (3) targeting traditional CVD risk factors (hypertension, smoking, hyperlipidemia, diabetes, obesity and physical inactivity) at a population level. Considering that 75% of US RA visits occur in specialty clinics, further research is needed regarding evidence-based strategies to manage and reduce CVD risk in RA.
Summary
This review highlights clinical updates including US cardiology and international professional society guidelines, successful evidence-based population approaches from primary care, and novel opportunities in rheumatology care to reduce CVD risk in RA.
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