Vitamin D plays an essential role in calcium absorption, but also has an immunomodulatory role through vitamin D receptors.1,7 Activated vitamin D inhibits the expression of IL-6, thus decreasing inflammation.1 The most recent recommendations by the National Committee for Quality Assurance/Physician Consortium for Performance Improvement (PCPI) advocate TB screening, periodic assessment of disease activity, glucocorticoid treatment and functional status assessment, and indicate that prescribing vitamin D is an integral part of clinical decision making. Thus, in RA patients, it is vital to check and maintain vitamin D at a sufficient level.
In our FQHC, although we may not prescribe biologics, such as etanercept, as primary care physicians, we can monitor and maintain vitamin D at a sufficient level in RA patients. Given that vitamin D plays an important role in anti-inflammation, we need to make sure we are following patients’ vitamin D levels closely. Additionally, vitamin D, along with other measures, such as weight-bearing exercises, is important for patients with RA to preserve bone health, which is important in the prevention of fractures. A vitamin D supplement, if necessary, is affordable for RA patients at all socioeconomic levels.
Currently, based on this chart review for quality measure, our FQHC is suboptimal at checking vitamin D levels in our RA patients; they are being checked only 28.5% of the time—meaning they are not checked 71.5% of the time. Of those who had vitamin D levels checked, 70% of the patients had deficient or insufficient levels, thus requiring supplements. Further, documentation of whether or not deficient or insufficient levels were replaced was not uniform.
Vitamin D has a key role in the inflammatory process, thus playing an important role in autoimmune diseases, such rheumatoid arthritis. In our federally qualified health clinic, where many of our patients are underinsured or uninsured, patients may not follow up with a rheumatologist. Although we may not manage biological medications, as primary care physicians, we can address patients’ RA inflammation and bone health through vitamin D. We can check their vitamin D levels at least once a year and prescribe the supplement to keep it at a sufficient level. Better adherence to RA guidelines, goals of disease management and documentation is required. This may be achieved through such interventions as physician (resident) education and use of clinical reminders in the FQHC, both of which are underway at this time.