1. Developing a National Audit
for Rheumatoid and Early
Inflammatory Arthritis
Ian Rowe
Chair Clinical Affairs Committee, BSR

2. 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

3. British Society for Rheumatology
• Covers England, Wales, Scotland and Northern Ireland
Membership
• Members include consultant rheumatologists, trainees, allied
organisation
health professionals and GPs
• Closer working with British Health Professionals in
Rheumatology (BHPR)
Guidelines and • Annual Conference over 2,000 clinicians
Education • E learning pilot 2012
• Rheumatology International Journal
• HQIP national audit of RA 2012
• Rheumatology conditions seen as outpatient activity rather than
Challenges ambulatory care and Long Terms Conditions
• Large variation in how services are delivered
• Little to inform service specifications
• Biologics register managed by BSR , over 25,000 patients
BSR Biologics Register
• Ankylosing Spondylitis register commenced 2012

4. 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.

5. RA-Variation in Quality and Outcomes
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
Europe unsuccessful Disease activity Score 3.2 (mild Spain waits 2 weeks from referral,
treatment with a disease) maximum Germany 12 weeks
single DMARD
U.K. unsuccessful Disease activity Score 5.1 U.K. standard set 3 months from
treatment with TWO (severe disease) symptom onset, not met
DMARD
Meeting Marks in the LSE England was given a 4/10 – the higher marks were awarded to
European report in 2012 lowest mark in joint placing with Germany (8/10) and Sweden (9/10).
guidelines Poland and Slovenia
Source: A Common Disease with Uncommon Treatment ,European Guideline Variations and , Access to Innovative Therapies for Rheumatoid Arthritis LSE June 2102

6. 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

7. Potential for other opportunities and use; potential
for links to other research databases e.g. CPRD; INBANK
Policy makers/
Regulators Patients
Pharma Biologics Researchers
Register
Clinicians/
Commissioners Specialist
nurses

8. 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

9. DANBIO
Courtesy of Merete Hetland

10. BSR and Healthcare Quality Improvement
Partnership (HQIP) Audit
• HQIP invited bids 2011
• BSR bid “ National Audit of Rheumatoid and Early
Inflammatory Arthritis” accepted 2012

11. 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

12. 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.

13. Healthcare Quality Improvement Partnership(HQIP)
National Audit Rheumatoid Arthritis
National Audit
for 3 years
potential to
extend for 5
2013 years
Spring Implementat
ion of
Summer
Spring 2013 national
2013 audit and
Contract let
Development data analysis
Autumn for national
and design of
2012 audit
implementati
Tender on
released for
provider
July 2012
bidding
Specification
workshop for
proposers
Themed workshops, stakeholder
engagement, testing and exercising

14. 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

15. 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)