Screen, Refer and Track: A Personalized Medicine and Systems-Based Approach to Improve the Outcomes of Patients with Rheumatoid Arthritis at Risk for Cardiovascular Disease at an Academic Medical Center

The goal of this initiative is to implement a novel rheumatology-focused cardiology consultation service and intervention program for rheumatoid arthritis (RA) patients with increased risk for cardiovascular (CV) disease. Our aims include: 1) increasing patient awareness of CV risks; 2) improving the practice for screening and documenting CV risk factors; 3) increasing referrals to systems-based resources that target modifiable risk factors; 4) promoting collaboration between rheumatology and cardiology departments; and  5) demonstrating improved patient outcomes related to modifiable risk factors.

To accomplish our goals of the program, we will implement systems-based changes and provide multidisciplinary education and resources to health care providers and patients with RA at risk for CV disease. Data from the electronic medical record (EMR), FitLogix® and Quitline® weight management and smoking cessation reporting systems, and patient surveys will be collected and tracked in a project-specific data registry. This effort will provide preventive care that is patient-centered and cost-effective for the health care system, and demonstrate a systemsbased process that can be replicated by other institutions nationwide.