Rheumatoid arthritis causes inflammation and damage to the joints. Increased activity of the pro-inflammatory pathways and auto-antibodies results in damage to the synovium, cartilage and bone.1 This can occur in any joint, but the hands and feet are commonly affected. The disease can also have extra-articular manifestations, including interstitial lung disease and scleritis. The severity of the disease varies between patients, and it is often associated with functional impairment and reduced mobility.
There is an increased risk of cardiovascular disease in patients with RA and patients have a higher risk of myocardial infarction. This is not fully explained by the traditional modifiable cardiovascular risk factors. Chronic systemic inflammation has been demonstrated to accelerate atherosclerosis, and this increased risk is related to the severity and duration of RA. In severe RA, the increased risk is comparable to that seen in diabetes. In addition cardiovascular risk is increased with the long-term use of non-steroidal anti-inflammatory drug (NSAID) treatment, including cyclo-oxygenase-II (COX-II) inhibitors.2 Osteoporosis and fragility fractures are also more common in patients with RA. The inflammatory process associated with active RA decreases bone density and thereby increases fracture risk. Reduced mobility and prolonged treatment with steroids also increase the risk of osteoporosis. The probability of developing cardiovascular disease and osteoporosis can be reduced if risk factors are identified and addressed early.
RA can have a significant impact upon the patient’s lifestyle. Pain, stiffness, fatigue and physical limitations can all result in work-related absences. Within two years of the onset of RA, one-third of patients stop work because of the disease, and this proportion continues to increase thereafter.
RA can also impact upon the patient’s relationships and activity of daily living, and there is an increased risk of depression, as in many chronic conditions.
There is a high risk of functional impairment and comorbidities, particularly in the elderly population or those with longstanding disease. Care is often co-ordinated by a rheumatology specialist nurse although the rheumatology multidisciplinary team includes specialists from occupational therapy, physiotherapy, podiatry, orthotics, pharmacy and psychology.
Health promotion, patient education and self-management plans are central principles in chronic disease management. The GP has a crucial role in the holistic care of patients with RA, and the King’s Fund has suggested that outcomes could be improved with “a more proactive approach to management among primary care professionals”.3 Implementing current guidelines and care standards demands collaboration between primary, secondary and sometimes tertiary care to achieve optimal outcomes.


Guidance
In order to address the multiple aspects of care, recent guidelines from NICE4 and The British Society for Rheumatology5 recommend that patients with RA have an annual review. This year RA has been included in the Department of Health’s Quality and Outcomes Framework (QOF) for GPs.6

Quality and Outcomes Framework
In the 2013–2014 QOF, the Department of Health introduced RA as a new clinical area (see box 1). These guidelines recommend that all adults with RA are on a register within the community.
The QOF guidelines recommend a face-to-face review with similar components to those within the guidelines from NICE and the British Society for Rheumatology (BSR) “Top Ten Quality Standards for RA”.
These guidelines recommend that both the RA disease activity and severity and the impact upon functioning and lifestyle be assessed. At this point, referrals to other members of the multidisciplinary team are to be considered, including consideration of surgical intervention.
There are QOF points for assessing the risk of the comorbidities of cardiovascular disease and osteoporosis. In addition, the NICE guidelines also advise assessing for systemic disease, organ damage and other comorbidities such as depression. The British Society for Rheumatology also calls for an action plan to address the issues that have been identified within the annual review. The annual review also allows an opportunity to discuss self-management, healthy lifestyle and any modifiable risk factors that are identified. 


Key components of the annual review
The guidance suggests that not all elements of the annual review would occur at the same time, and therefore there should be clearly defined responsibilities for the components of the annual review with collaboration between primary and secondary care. The individual components must be coded by the GP practice in order to gain QOF points. Within the annual review of patients with RA, there are key topics which should be addressed:

Disease activity and functional ability
It is important to assess RA disease activity and response to treatments with an objective and reproducible tool. The most widely used is the DAS28 score. It is recommended by NICE and is also used to assess eligibility for biologic therapy.
The DAS28 score uses the examination findings of 28 joints and the number of tender and swollen joints are recorded. This is combined with a recent inflammatory markers result (CRP or ESR) and a patient reported visual analogue score (VAS) of overall how they feel their health is currently, marked on straight line from 0 (best) to 100 (worst). The score of the individual components is used to calculate a composite disease activity score (DAS28 CRP or DAS28 ESR). Online DAS28 calculators are widely available.7
The intention of treatment is to suppress disease activity, and the target is a DAS28 score of less than 3.2. The DAS28 score is useful in guiding escalation of treatment to control disease, or guide cautious withdrawal of treatment when disease is controlled. However, it is criticised for excluding assessment of the feet or systemic complications. Treatment decisions should be made with the rheumatologist, but options include combination DMARDs, short-term adjuvant corticosteroids or biologic therapy.
Pain management is another important facet of managing RA, and includes simple analgesics, NSAIDs and COX-II inhibitors. Consideration of TENS machine, wax baths and orthotics are included in the guidance and are examples of the central role that the multidisciplinary team plays in pain management.
The Health Assessment Questionnaire (HAQ) gives a composite score from patient reported outcomes to quantify functional ability. This questionnaire covers activities of daily living such as washing, walking and eating.
The patient grades their functional limitation (eg. without difficulty, with some or much difficulty, or not possible), and includes whether the patient is dependent upon others or functional aids for certain activities. There is an online tool for HAQ.8
The assessment of disease activity and functional ability at the annual review gives an opportunity to compare the patient’s disease from one year to the next and to determine whether onward referral or support would be useful.
The QOF guidelines also specifically mention considering surgery. The patient may also benefit from other members of the multidisciplinary team, such as occupational therapy or physiotherapy.

Impact of RA upon the patient’s lifestyle—work, relationships and mood
RA can impact upon the patient’s self-image and upon their relationships. Many patients also experience difficulties at work, with flares of RA, pain, fatigue and physical limitations. There is a wealth of support available to patients, and self-management plans are central in this. Employment has been shown to be important for self-confidence and personal identity and to reduce depression and pain. Work-related absence is a major issue for patients with RA.9
The employer is required to make “reasonable adjustments” which can be recommended by occupational therapists and physiotherapists. When patients experience flares of the disease, prompt access to medical care can minimise absence. There is relevant information and support available for patients to access, and the National Rheumatoid Arthritis Society (NRAS) website specifically has booklets about employment for both the patient and their employer.
Amongst other NRAS publications is the booklet Emotions, Relationships and Sexuality, which addresses common emotional and relationship difficulties that surround the diagnosis of RA. It suggests ways in which the patient can communicate with others about RA and the problems surrounding the diagnosis. NRAS also has a helpline and holds meetings throughout the UK,
and has a patient self-management course.
Patients with RA also have an increased risk of depression. The NICE guidelines for depression and chronic physical health problems10 provide two questions to screen for depression. These are:
• During the last month, have you often been bothered by feeling down, depressed or hopeless?
• During the last month, have you often been bothered by having little interest or pleasure in doing things?
If the patient answers yes to either, then further assessment and intervention should be considered.

Cardiovascular risk assessment
The RA QOF also recommends a cardiovascular risk assessment during the annual review. The assessment must take into account the increased cardiovascular risk that is associated with RA; at present, QRISK2 is the only tool validated for patients with RA.11 This algorithm calculates the risk of the patient having a myocardial infarction or stroke within the following 10 years. A QRISK2 calculator has been incorporated into some primary care software systems and is also accessible online.12
The modifiable risk factors within the QRISK2 algorithm are smoking status, systolic blood pressure, cholesterol/HDL ratio and body mass index. Cardiovascular risk assessment provides an opportunity for these modifiable risk factors to be addressed, including a personalised self-management plan. Anti-hypertensive and lipid-lowering medication should be considered, along with weight management programmes where appropriate.
Smoking is associated with poor prognosis for patients with RA, and as well as other important concerns (including cardiovascular, malignancy and fracture risk), it is particularly important to promote smoking cessation and provide further support within the community setting.

Fracture risk assessment and bone health
Due to increased risk of osteoporosis and subsequent fractures in patients with RA, QOF recommends that the fracture risk is calculated at least every two years. There are two assessment tools available, the World Health Organization’s FRAX” tool13,14 and QFracture. Both calculate the 10 year risk of having an osteoporotic fracture or hip fracture. Fracture risk assessment provides an opportunity to address the patient’s modifiable risk factors which include smoking, excess alcohol intake and deficiencies of vitamin D and calcium. Long-term steroid therapy should also be reviewed as a potentially modifiable risk factor. If the fracture risk is predicted to be intermediate or high, then bone density scanning and bone protecting treatment should
be considered. 


Summary
The management of RA demands a holistic, multidisciplinary approach. The annual review provides an opportunity to address health promotion and co-ordinate different aspects of care, and these new guidelines provide a framework for this. The key topics to include in the RA annual review are the assessment of disease activity and functional ability, the impact of RA upon the patient’s life and whether referrals to other members of the multidisciplinary team would be beneficial. Risk assessment for cardiovascular disease and osteoporotic fractures should result in specific interventions to reduce the risk of developing these common comorbidities. Collaboration between primary and secondary care for the annual review should improve outcomes for patients with RA. 


Conflict of interest: none declared
References

1. Scott D, Wolfe F, Huizinga T. Rheumatoid arthritis. The Lancet 2010; 376: 1094–1108
2. Kelt I, Neal Uren N. Cardiovascular risk in rheumatoid arthritis. Br J Cardiol 2009; 16:113–15
3. Goodwin N, Curry N, Naylor C et al. Managing people with long-term conditions: An inquiry into the quality of general practice in England. London: the King’s Fund, 2010
4. Rheumatoid arthritis, The management of rheumatoid arthritis in adults NICE clinical guideline 79, 2009. http://guidance.nice.org.uk/CG79 Accessed 10/01/14
5. Top 10 Quality Standards for RA, The British Society for Rheumatology 2012. http://www.rheumatology.org.uk/includes/documents/cm_docs/2012/t/top_10_quality_standards_for_ra.pdf Accessed 10/01/14
6. Quality and Outcomes Framework guidance for GMS contract 2013/14, 2013. http://bma.org.uk/practical-support-at-work/contracts/independent-contractors/qof-guidance Accessed 10/01/14
7. Disease Activity Score Calculator for Rheumatoid Arthritis http://www.4s-dawn.com/DAS28/ Accessed 10/01/14
8. http://www.4s-dawn.com/HAQ/HAQ-DI.html
9. National Rheumatoid Arthritis Society. http://www.nras.org.uk/ Accessed 10/01/14
10 Depression in adults with a chronic physical health problem. NICE clinical guideline 91, 2009. http://www.nice.org.uk/CG91 Accessed 10/01/14
11 Hippisley-Cox J, Coupland C, Vinogradova Y, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2, BMJ 2008; 336(7659): 1475–82
12. QRisk. http://qrisk.org/ Accessed 10/01/14
13. Frax. http://www.shef.ac.uk/FRAX/ Accessed 10/01/14
14. http://www.qfracture.org/. Accessed 10/01/14