Quality standard

Quality statement 2: Treatment

Quality statement

Adults with active rheumatoid arthritis start conventional disease-modifying anti-rheumatic drug (cDMARD) monotherapy within 6 weeks of referral, with monthly monitoring until their treatment target is met. [2013, updated 2020]

Rationale

Starting treatment quickly give the best chance of improving long-term outcomes such as joint damage, joint function and quality of life for adults with active rheumatoid arthritis. Regular monitoring of C-reactive protein (CRP) and disease activity allows for the dose of cDMARDs to be adjusted as needed. Intensive treatment monitoring and adjustment, with the aim of maintaining remission, or low disease activity if remission cannot be achieved, results in better long-term function and quality of life for adults with rheumatoid arthritis.

Quality measures

Structure

a) Evidence of local arrangements to start treatment with cDMARD monotherapy for adults with active rheumatoid arthritis within 6 weeks of referral from primary care.

Data source: Local data collection, for example, service protocols and treatment strategies.

b) Evidence of local arrangements to measure CRP and disease activity monthly in adults with active rheumatoid arthritis until they are in remission or have low disease activity if remission cannot be achieved.

Data source: Local data collection, for example, service protocols and treatment strategies.

Process

a) Proportion of adults with suspected persistent synovitis who have specialist assessment within 3 weeks of referral from primary care.

Numerator – the number in the denominator who have specialist assessment within 3 weeks of referral.

Denominator – the number of adults with suspected persistent synovitis referred to rheumatology services.

Data source: The National Early Inflammatory Arthritis Audit collects data on time from referral to specialist assessment.

b) Proportion of adults with active rheumatoid arthritis starting cDMARD monotherapy within 6 weeks of referral from primary care.

Numerator – the number in the denominator who start cDMARD monotherapy within 6 weeks of referral.

Denominator – the number of adults with active rheumatoid arthritis referred to rheumatology services.

Data source: Local data collection, for example, audit of electronic prescription records. The National Early Inflammatory Arthritis Audit collects data on time from referral to initiation of cDMARD therapy.

c) Proportion of adults with active rheumatoid arthritis who have their CRP and disease activity score measured monthly.

Numerator – the number in the denominator who had their CRP and disease activity score measured within the past month.

Denominator – the number of adults with active rheumatoid arthritis.

Data source: Local data collection, for example, audit of patient records.

Outcome

a) Disease activity for adults with rheumatoid arthritis.

Data source: The National Early Inflammatory Arthritis Audit collects data on mean disease activity score (DAS28) at baseline, 3-month and 12-month follow-up.

b) Health-related quality of life for adults with rheumatoid arthritis.

Data source: The National Early Inflammatory Arthritis Audit collects data on patient-reported quality of life, including symptoms, wellbeing, impact on daily life and work, in the patient questionnaire at baseline, 3-month and 12-month follow-up.

What the quality statement means for different audiences

Service providers (such as rheumatology services) ensure that systems are in place for adults with active rheumatoid arthritis to start cDMARD monotherapy within 6 weeks of referral from primary care. They also ensure that staff from the multidisciplinary team are trained to perform monthly monitoring of active rheumatoid arthritis.

Healthcare professionals (such as rheumatology consultants, rheumatology specialist registrars and specialist nurses) start cDMARD monotherapy for adults with active rheumatoid arthritis within 6 weeks of referral. They measure CRP and disease activity monthly until the target of remission, or low disease activity if remission cannot be achieved, is met.

Commissioners (such as clinical commissioning groups) commission rheumatology services that have capacity for adults with active rheumatoid arthritis to start treatment with cDMARD monotherapy within 6 weeks of referral. They check whether services undertake monthly monitoring for adults with active disease.

Adults with active rheumatoid arthritis start treatment within 6 weeks of seeing their GP. They also have monitoring each month until they have achieved their treatment target.

Source guidance

Definitions of terms used in this quality statement

Treatment target

A treat-to-target strategy should be used for adults with rheumatoid arthritis. This defines a treatment target (such as remission or low disease activity if remission cannot be achieved) based on a composite score such as DAS28 and applies tight control (such as monthly monitoring with treatment adjustment) to reach this target. The treatment strategy often follows a protocol for adapting treatment depending on the disease activity level and degree of response to treatment.

[Adapted from NICE's guideline on rheumatoid arthritis in adults, recommendations 1.2.1, 1.2.3 and terms used in this guideline]

Equality and diversity considerations

Some medicines used in the treatment of rheumatoid arthritis should not be prescribed for adults who are planning a pregnancy, pregnant or breastfeeding. Treatment goals may also be different during pregnancy or when breastfeeding. See the British Society for Rheumatology and British Health Professionals in Rheumatology guideline on prescribing DMARDs in pregnancy and breastfeeding.