Does not apply to this measure

This measure is used to assess the percentage of patients with rheumatoid arthritis who have surgery requiring general anesthesia for whom there is management or documentation of the risk of atlanto-axial instability.

Identification of instability will alter airway management and minimize the risk of spinal cord impingement and/or superior migration of the odontoid.

A number of studies have demonstrated that involvement of the cervical spine is common among patients with early or late disease and is associated with poor outcomes.

Rheumatoid arthritis; general anesthesia; atlanto-axial instability; cervical spine radiographs

Patients with rheumatoid arthritis who have surgery requiring general anesthesia

Patients for whom there is management or documentation of the risk of atlanto-axial instability

• A formal consensus procedure involving experts in relevant clinical, methodological, and organizational sciences
• One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Unspecified

Current routine use

Internal quality improvement

Hospitals

Physicians

Individual Clinicians

Unspecified

Either male or female

Unspecified

• Rheumatoid arthritis (RA) affects one percent of the adult population. RA affects approximately 2.5 million Americans, disproportionately women.
• Approximately 40% to 85% of patients with RA develop neck pain and radiographic evidence of instability (atlanto-axial subluxation, and superior migration of the odontoid process) and 50% of these patients are asymptomatic. In a prospective observational study of 100 patients with early RA (less than one year duration), 12% developed atlanto-axial subluxation within the first five years of disease. Patients in another early RA (mean disease duration 6.1 months) cohort followed prospectively for a mean of 6.5 years showed atlanto-axial subluxation (30%) at the end of the study. Four out of 67 patients already had evidence of atlanto-axial subluxation at the entry and the rest of them developed gradually despite being on disease modifying anti-rheumatic drugs (DMARD) therapy.
• In a retrospective cross-sectional study, pre-operative cervical spine x-rays were obtained for 128 patients with asymptomatic RA scheduled for elective orthopedic surgery. The overall incidence of craniocervical instability was 16%; previously undetected atlanto-axial subluxation was found in 6%. None of the patients had signs or symptoms related to cervical cord compression.

See the "Incidence/Prevalence" field.

• Forty percent of patients with early rheumatoid arthritis (RA) (less than six months of symptoms) have erosive disease at presentation and remission is rare (less than 5%).
• The mortality associated with atlanto-axial subluxation and instability is described in a retrospective observational study of autopsies performed on RA patients over a five-year period in a single hospital. During the five-year period, 254 hospitalizations were for RA, and 104 RA-related deaths were autopsied. Investigators found that 10% died as a result of unrecognized spinal cord or brain stem compression secondary to atlanto-axial dislocation. Review of the premorbid clinical histories of these 11 patients revealed that three had no neurological signs or symptoms, three had nonspecific neurological symptoms and five had symptoms suggestive of atlanto-axial instability (hemiplegia, vertigo, dysphagia, transient extensor reflex.

Over nine million physician visits and greater than 250,000 hospitalizations are attributed to rheumatoid arthritis (RA) per year.

Rheumatoid arthritis (RA) has significant economic implications for the individual patient, as well as for society. Individuals with RA have 3 times the direct medical costs, twice the hospitalization rate and 10 times the work disability rate on an age- and sex-matched population. A recent study has shown annual medical costs for a patient with RA to be approximately $8,500. Annual costs rise as the duration of the disease increases and as function declines. Indirect costs related to disability and work loss have been estimated to be 3 times higher than the direct costs associated with the disease.

Living with Illness

Effectiveness
Safety

Users of care only

Patients with rheumatoid arthritis who have surgery requiring general anesthesia

Patients associated with provider

Inclusions
Patients with rheumatoid arthritis who have surgery requiring general anesthesia

Exclusions
Unspecified

All cases in the denominator are equally eligible to appear in the numerator

Clinical Condition
Therapeutic Intervention

Time window is a single point in time

Inclusions
Patients for whom there is management or documentation of the risk of atlanto-axial instability

Exclusions
Unspecified

The measure results are somewhat or substantially under the control of the health care professionals, organizations and/or policymakers to whom the measure applies.

Encounter or point in time

Administrative data
Medical record

Individual Case

Unspecified

Rate

Better quality is associated with a higher score

Unspecified

Internal time comparison

Using a modification of the RAND Corporation/University of California Los Angeles (RAND/UCLA) Appropriateness Method, a multi-disciplinary expert panel comprised of nationally recognized experts in arthritis, primary care, and pain management discussed and rated the validity of each of the proposed measures based on 1) a summary of the evidence to support or refute each proposed measure and 2) their expert opinion.

Quality indicator 5. Radiographs of the cervical spine.

Arthritis Foundation

Arthritis Foundation
RAND Health

Unspecified

Unspecified

Unspecified

Measure was not adapted from another source.

2005 Jan

This is the current release of the measure.

This NQMC summary was completed by ECRI on October 23, 2006. The information was verified by the measure developer on February 1, 2007.

No copyright restrictions apply.