Quality statement 5: Disease control

Quality statement

People who have active rheumatoid arthritis are offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

Rationale

Monthly treatment escalation is important to achieving disease control rapidly, which results in a lower disease activity, and therefore reduced impact of the disease in terms of joint function and everyday living. The low disease activity target is agreed with the patient to maximise shared decision-making and patient satisfaction with their functional ability and suppression of symptoms.

Quality measure

Structure: Evidence of local arrangements to ensure that people with active rheumatoid arthritis receive monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

Process:
a) Proportion of people with active rheumatoid arthritis who receive monthly treatment escalation.

Numerator – the number of people in the denominator who receive monthly treatment escalation.

Denominator – the number of people with active rheumatoid arthritis.

b) Proportion of people with previously active rheumatoid arthritis whose disease is currently controlled, who received monthly treatment escalation until the disease was controlled to an agreed low disease activity target.

Numerator – the number of people in the denominator who received monthly treatment escalation until the disease was controlled to an agreed low disease activity target.

Denominator – the number of people with previously active rheumatoid arthritis whose disease is currently controlled.

Outcome:
a) Controlled rheumatoid arthritis.

b) Functional ability.

What the quality statement means for each audience

Service providers ensure systems are in place for people with active rheumatoid arthritis to be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

Healthcare professionals ensure that people with active rheumatoid arthritis are offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

Commissioners ensure they commission services that enable people with active rheumatoid arthritis to be offered monthly treatment escalation until the disease is controlled to an agreed low disease activity target.

People with active rheumatoid arthritis are offered monthly increases in treatment dose until the disease is controlled to an agreed level.

Source guidance

NICE clinical guideline 79 recommendations 1.5.1.1 and 1.5.1.2 (key priority for implementation).

Data source

Structure: Local data collection.

Process:
a) and b) Local data collection. Contained within the Commissioning for Quality in Rheumatoid Arthritis (CQRA) Patient metric data collection form for recent onset rheumatoid arthritis.

Outcome:
a) and b) Local data collection.

Definitions

Active rheumatoid arthritis constitutes disease that cannot be considered as being adequately controlled to a level agreed between patient and rheumatologist. A disease activity score (measured using DAS28 for example) can be used to provide an objective indication of the level of activity, but a specific score cannot be prescribed for all patients as this is a matter for clinical judgement.

Treatment escalation relates to the use of disease-modifying antirheumatic drugs, glucocorticoids or biological drugs to control the disease (in accordance with relevant NICE technology appraisals), and a review of the treatment in terms of disease response and patient safety.

Disease activity is measured using a composite score such as DAS28.

An agreed low disease activity target is a level of low disease activity, ideally remission, or functional ability that is agreed with each person as their goal for ongoing management of the disease.

Controlled disease represents the agreed target being achieved and the person being satisfied with their functional ability and suppression of symptoms. Uncontrolled disease is any level of disease that doesn't meet the agreed target.

Functional ability can be measured using the Health Assessment Questionnaire.