Quality statement 3: Starting treatment

Quality statement

People with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.

Rationale

Rapid initiation of treatment optimises the 'window of opportunity' within which effective treatment can improve long-term outcomes such as joint damage, joint function and quality of life.

Quality measure

Structure: Evidence of local arrangements for people with newly diagnosed rheumatoid arthritis to receive short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs from a rheumatology service within 6 weeks of referral.

Process: Proportion of people with newly diagnosed rheumatoid arthritis who receive short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs from a rheumatology service within 6 weeks of referral.

Numerator – the number of people in the denominator who receive short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs from a rheumatology service within 6 weeks of referral.

Denominator – the number of people with newly diagnosed rheumatoid arthritis.

What the quality statement means for each audience

Service providers ensure systems are in place for people with newly diagnosed rheumatoid arthritis to be offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.

Healthcare professionals ensure that people with newly diagnosed rheumatoid arthritis are offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.

Commissioners ensure they commission services that enable people with newly diagnosed rheumatoid arthritis to be offered short-term glucocorticoids and a combination of disease-modifying anti-rheumatic drugs by a rheumatology service within 6 weeks of referral.

People with newly diagnosed rheumatoid arthritis are offered a short course of glucocorticoids (steroids) and a combination of drugs called DMARDs (disease-modifying anti-rheumatic drugs) by a rheumatology service within 6 weeks of referral.

Source guidance

NICE clinical guideline 79 recommendation 1.4.1.1 (key priority for implementation).

Data source

Structure: Local data collection.

Process: Local data collection. Contained within the British Society for Rheumatology National clinical audit for rheumatoid and early inflammatory arthritis and within the Commissioning for Quality in Rheumatoid Arthritis (CQRA) Patient metric data collection form for recent onset rheumatoid arthritis.

Definitions

Timeframe derived from expert consensus and is consistent with best practice (as defined in the 2013–14 best practice tariff for early inflammatory arthritis).

People with newly diagnosed rheumatoid arthritis are those attending the rheumatology service without a previous diagnosis of rheumatoid arthritis, who have been diagnosed after assessment within the service.

A rheumatology service comprises a specialist multidisciplinary team, all of whom have expertise in managing rheumatoid arthritis. The team is led by 1 or more consultant rheumatologists and includes nurse consultants, nurse specialists, physiotherapists, occupational therapists, podiatrists and orthotists. It has access to supporting specialties including orthopaedic surgery, psychology, radiology with rheumatological ultrasound and MRI experience, and may also have rheumatology doctors in training.

Monotherapy should be started in people with newly diagnosed rheumatoid arthritis for whom combination disease-modifying anti-rheumatic drug therapy is not appropriate (for example, because of comorbidities or pregnancy), and greater emphasis placed on fast escalation to a clinically effective dose rather than on the choice of disease-modifying anti-rheumatic drug.

People receiving treatment with disease-modifying anti-rheumatic drug therapy need frequent monitoring to check for any adverse events and assess response to treatment. Certain aspects of this monitoring may be delegated to other healthcare professionals and completed in non-specialist settings under formalised shared care arrangements.