Developing a National Audit

for Rheumatoid and Early

Inflammatory Arthritis

Ian Rowe

Chair Clinical Affairs Committee, BSR

Outline

• The British Society for Rheumatology

• Challenges in improving patient outcomes for RA in UK

• What is the BSR Biologics Register ?

• Approach to the HQIP National Audit in RA

• Opportunities

British Society for Rheumatology

Membership

organisation

• Covers England, Wales, Scotland and Northern Ireland

• Members include consultant rheumatologists, trainees, allied

health professionals and GPs

• Closer working with British Health Professionals in

Rheumatology (BHPR)

Guidelines and

Education

• Annual Conference over 2,000 clinicians

• E learning pilot 2012

• Rheumatology International Journal

• HQIP national audit of RA 2012

BSR Biologics Register • Biologics register managed by BSR , over 25,000 patients

• Ankylosing Spondylitis register commenced 2012

• Rheumatology conditions seen as outpatient activity rather than

ambulatory care and Long Terms Conditions

• Large variation in how services are delivered

• Little to inform service specifications

Challenges

Defining Rheumatology

A multidisciplinary branch of medicine that deals with the investigation,

diagnosis and management of patients with arthritis and other

musculoskeletal conditions. This incorporates over 200 disorders affecting

joints, bones, muscles and soft tissues, including inflammatory arthritis and

other systemic autoimmune disorders, vasculitis, soft tissue conditions,

spinal pain and metabolic bone disease. A significant number of

musculoskeletal conditions also affect other organ systems.

Rheumatology is in the midst of a period of exponential growth in knowledge of

the mechanisms of rheumatologic and auto-immune disease, knowledge

which is transforming and advancing our treatment options.

There is untapped potential for Quality improvement through addressing

variation in treatment and care; Innovation through implementing best

practice; Prevention of unnecessary disability and improvements in

Productivity.

British Society for Rheumatology Dec 2011.

Innovation and Productivity: Early effective treatment needed; RA/IA represent a major health problem; 1

million people (England); cost £8 billion annually (UK); delays in treatment can result in a more

aggressive disease; earlier treatment may produce cost savings.

Quality Improvement: Major Variations in Care

National: Different levels of Care and variation in services

i) There is existing wide variation in treatment and outcomes; e.g. only 10% of patients are put onto

DMARDs within 3 months of symptom onset in spite of NICE guidelines.

ii) Only 63% of patients in acute trusts provided annual review for RA patients to monitor disease

progression and emergence of co-morbidities (NAO, 2009; NICE, 2009)

International : Poorer Access: Biologic Treatment and Waiting times

RA-Variation in Quality and Outcomes

Europe unsuccessful

treatment with a

single DMARD

Disease activity Score 3.2 (mild

disease)

Spain waits 2 weeks from referral,

maximum Germany 12 weeks

U.K. unsuccessful

treatment with TWO

DMARD

Disease activity Score 5.1

(severe disease)

U.K. standard set 3 months from

symptom onset, not met

Meeting

European

guidelines

Marks in the LSE

report in 2012

England was given a 4/10 – the

lowest mark in joint placing with

Poland and Slovenia

higher marks were awarded to

Germany (8/10) and Sweden (9/10).

Source: A Common Disease with Uncommon Treatment ,European Guideline Variations and , Access to Innovative Therapies for Rheumatoid Arthritis LSE June 2102

BSR Biologics Register RA

Largest European biologics register for patients with RA

• Established 2001

• Monitoring long term safety profile

• Now >25,000 patients

• Cohorts of patients recruited

• Six different biologic drugs

• Research database: infection risk; comparison between drugs

• Established as part of NICE approval for biologics

• Funded by pharmaceutical companies

• Paper moving to electronic data capture

Clinicians/

Specialist

nurses

Pharma

Policy makers/

Regulators

Commissioners

Researchers

Patients

Biologics

Register

Potential for other opportunities and use; potential

for links to other research databases e.g. CPRD; INBANK

ARUK- plans for INBANK

A national research infrastructure to facilitate

coordinated musculoskeletal research, including

i) a searchable catalogue of extant studies and

ii) a prospective research database

- recruitment to bespoke studies

- biological samples

- linkage to national datasets

DANBIO

Courtesy of Merete Hetland

BSR and Healthcare Quality Improvement

Partnership (HQIP) Audit

• HQIP invited bids 2011

• BSR bid “ National Audit of Rheumatoid and Early

Inflammatory Arthritis” accepted 2012

National Institute for Health and Clinical

Excellence (NICE)

• RA Guidelines 2009

• DMARDs within 3 months of symptom onset

• Measure CRP and key components of disease activity

(DAS) monthly until disease controlled

• Annual review for disease assessment, co-morbidities,

MDT, effect of RA on person’s life

3 Key Audit Objectives

• Rapid control of joint inflammation: Audit data on new

patients for 1 month in rheumatology clinics with follow up

data over 3 months. Key outcomes include patient

recorded disease severity, satisfaction with access to

service, advice and education (NICE). Repeat annually.

• Cardiovascular risk factors: Audit at RA annual review

(NICE) in collaboration with Primary Care. One month

annually.

• Ability to work: generate work related outcomes and audit

with above.

National Audit

for 3 years

potential to

extend for 5

years

Themed workshops, stakeholder

engagement, testing and exercising

July 2012 Specification workshop for proposers

Autumn 2012 Tender released for provider bidding

Spring 2013 Contract let for national audit

Spring Summer 2013 Development and design of implementation

2013 Implementation of national audit and data analysis

Healthcare Quality Improvement Partnership(HQIP)

National Audit Rheumatoid Arthritis

Minimum Core Dataset to enable future

developments – collect data once

• Data direct from the clinical setting

• Disease monitoring

- adverse events

- lifestyle factors

- CV risk factors

• Collect outcomes important to

patients

• Inform patient decision making

Improved quality and consistency of

rheumatology services - Challenges and

opportunities

• Clinical engagement for data collection- user friendly IT

• Patient engagement

• Continuous data collection

• Clinical- routine practice, audit (local and national), revalidation

• Discussion with devolved nations

• Research (BSRBR, other databases)