NEIAA: driving EIA service quality in a shifting clinical landscape

The National Early Inflammatory Arthritis Audit (NEIAA), commissioned by the UK Health Quality Improvement Partnership (HQIP) and run by the British Society for Rheumatology (BSR), launched in May 2018 and will continue until at least October 2022. The audit set out to assess early inflammatory arthritis care quality across all rheumatology departments in England and Wales, by measuring the care provided to suspected and new confirmed adult cases. NEIAA supplies care providers with nationally benchmarked information on their services. During its first year, NEIAA captured data on over 20 000 people presenting to rheumatology services for the first time. Patient outcomes and service performance over the first year of data collection were published in October 2019. A supplementary report more recently published information on annual review processes and on patient outcomes after 12 months of specialist care. Both reports can be found at www.rheumatology.org.uk/practice-quality/audits/neiaa. The headlines are relevant to the rheumatology community: wide variation exists in staffing levels, meeting of treatment targets and patient outcomes. Nationally, referral from primary care was frequently delayed (41% referred within the 3-day recommended target), hospital assessments took place on average 28 days after referral was received and DMARDs were started within 6 weeks of referral (the national target) in just over half (54%) of people. Just over a third (35%) of patients were enrolled into an early inflammatory arthritis management pathway. In addition to process measures, NEIAA also collects information on clinical outcomes. The first annual report documented the positive impact of specialist care within 3 months and the supplementary report has shown progressive and substantial benefits after 12 months; 54% of people were in remission at 12 months. Remission associated with DMARD initiation within 6 weeks of referral, reinforcing the findings published as long ago as 1992 [1] that the disease appears to accumulate damage at a greater speed early on in its course, and treatments are most likely to lead to lasting remission if commenced early [2]. Capture of patient-derived outcomes via NEIAA has been high and all measures assessed (disability, mental health and ability to work) show significant improvement over time. The number of patients with a positive screen mental health comorbidity almost halved, and overall work impairment fell by 8.4% from initial assessment to 12 months. Linkages to other national datasets have allowed reporting on unplanned admissions, joint replacement surgery and mortality. The variation in unplanned admissions is particularly striking and will need to be a focus for further work. An important aspect of care that was not available to the majority of patients is the annual review process; this was only reported to have occurred in 43% of patients and when it did take place it frequently did not include assessment of bone health, cardiovascular risk and disability. The barriers to annual review also need further study. The sheer volume of people enrolled into this nationally funded audit shows that ambitious initiatives such as this can be a success with the support and motivation of the relevant community; learning can also be shared worldwide. The results are a source of optimism for the specialty. Significant improvements have been shown both when compared with the previous audit in 2016 and during the first year of the new audit. Remission rates and improvements in patient reported outcomes after 3 and 12 months of specialist care are extremely encouraging, although further improvement is needed. The variation in staffing and performance across hospitals is wide and the place a patient receives care has ultimately been shown to be an important predictor of clinical outcome. Although there is always discomfort and anxiety in reporting poor results, our learning is that making nationally benchmarked data publicly available acts as a powerful lever for service improvement. Several providers identified as low performers achieved remarkable improvements over a short period of time. There is an increasing appreciation across the healthcare community that having evidence-based guidelines is only the first step to delivering high quality healthcare. Meeting the standards set out in guidelines is another challenge entirely. There have been many questions raised about the value of NEIAA, including for how long it should continue. Lessons from the field of quality improvement research are clear: to maintain quality, monitoring needs to be continuous. Episodic audit only has small and short-lived effects on performance indicators. It is already apparent that NEIAA is driving a sustained change in outcomes for patients. The project continues to receive national funding in recognition of its value to the rheumatology community, to the wider health economy and to every person living with early inflammatory arthritis. Following the necessary interruption of work (data capture was suspended from 27 March 2020 through the peak of the COVID-19 pandemic) a renewed focus on this audit and on early inflammatory arthritis services is required. Social distancing measures to control the COVID-19 pandemic will be a further challenge to service providers worldwide. NEIAA is ideally positioned to assess the pandemic’s impact on services available to early inflammatory arthritis patients in England and Wales, with learning that can again be shared worldwide. An additional benefit of NEIAA is that processes have been put in place to support release of data for research proposals, with the potential for further learning. It is essential that, as a worldwide community, we strive to offer the best care for patients and share our learning. Understanding the barriers to optimal care is crucial, with many unlikely to be exclusive to rheumatology service providers in England and Wales. We look forward to further sharing our experiences with the international rheumatology community to facilitate the establishment of similar projects. There have been huge challenges in setting up this audit, but the value is now starting to be appreciated and the potential for international collaboration would be an exciting next step. M.Y.’s salary is funded by the BSR and Versus Arthritis; NEIAA is funded by HQIP. Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript. Disclosure statement: The authors have declared no conflicts of interest.