ACR Quality Performance Indicators for Rheumatoid Arthritis: Benchmarking, Variability, and Opportun

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ACR Quality Performance Indicators for Rheumatoid
ArthritisBenchmarking, Variability, and
Opportunities to Improve Quality of CareL
Adhikesavan, E Newman, A Bili, M Diehl, G Wood
Geisinger Health System, Danville, PA
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Why focus on improving quality?

• Glass half empty
• Increasing problems with traditional health care
• Therapies more complex and more effective
• Outcome expectations are increasing
• Revenues are at risk and tied to performance
• Glass half full
• Its what we want for our patients

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What is happening in the quality arena on a
national level?

• External groups are establishing indicators of
  performance and quality
• NCQA, AMA PCPI develops
• AQA implements
• NQF endorses
• CMS pays (or not)

NCQA National Committee for Quality
Assurance AMA PCPI American Medical Association
Physician Consortium for Performance
Improvement AQA Ambulatory Quality Alliance NQF
National Quality Forum
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What is happening in the quality arena on a
national level?

• ACR is taking a proactive stance
• Rheumatologists are the most qualified physicians
  to establish measures reflecting the highest
  quality of rheumatologic care
• Establishment of Quality Measures Committee
• Development of Quality Performance Indicators
  (QPIs) Starter Set

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ACR Quality Performance Indicators (QPIs)

• Previous Work in Rheumatoid Arthritis (RA) QPIs
• Methods - 568 RA patients using patient self
  report surveys/medical record review
• Results adherence rates moderate/high
• Limitations not a population of RA patients
  treated by rheumatologists, only insured patients
  who agreed to participate

Kahn KL et al. Assessment of American College
of Rheumatology quality criteria for rheumatoid
arthritis in a pre-quality criteria patient
cohort. Arthritis Rheum 2007 57707-715.
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Purpose

• Measure how rheumatologists across our health
  care system performed with the Rheumatoid
  Arthritis (RA) and Methotrexate (MTX) Drug Safety
  QPIs
• Understand the variability
• Develop opportunities for improvement

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Geisinger Health System Department of
Rheumatology Demographics

• Distinct
• 3 geographic locations (city, town, rural)
• 3 types of practices
• Shared
• Electronic health record (EHR)
• Patient centric care philosophy
• Redesign methodology interest

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Methods

• Patient population
• Diagnosis of RA
• 10 staff rheumatologists and 5 fellows
• November 1, 2005 October 31, 2006
• Data extraction
• Electronic query using EHR (EPIC?)
• Manual electronic chart review

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Methods

• QPI-1 RA Core Dataset
• Joint exam, functional status, acute phase
  reactant, pain, physician global, and patient
  global within 3 months of diagnosis and at least
  annually
• QPI-2 RA DMARD Use
• On Disease Modifying Antirheumatic Drug (DMARD )
  unless contraindication, inactive disease or
  refused
• QPI-3 Intervene if RA Worse
• If increased disease activity or progression of
  bony damage over 6 months, then change/add/adjust
  DMARD or glucocorticoid unless refused or
  contraindicated

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Methods

• QPI-4 MTX Risks Discussed
• If newly prescribed MTX, document risk discussion
  
• QPI-5 MTX Baseline Studies
• If newly prescribed MTX, perform baseline
  hemoglobin (Hgb) or hematocrit (Hct), WBC,
  platelet count, creatinine, AST or ALT, albumin,
  alkaline phosphatase and assure Chest X-ray done
  within previous year
• QPI-6 MTX Followup Studies
• If ongoing MTX treatment, perform Hgb or Hct,
  WBC, platelet count, creatinine, AST or ALT, and
  albumin at least every 8 weeks

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Methods

• Analysis
• Basic demographics
• Percentage 95 CI met
• Performance analysis
• Sub-analysis
• Years of experience
• General estimation equation model
• Data Extraction Work Effort Analysis

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Results

• 1,062 RA patients

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Results
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Results
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Results
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Results
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Results
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Results
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Results

• Data Extraction Work Effort Analysis
• Total EHR patient chart review time 179.3 hours
• Average EHR patient chart review time 10 minutes

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Conclusions

• Improving Quality of Rheumatologic Care is
  paramount
• We dont understand what we dont measure
• ACR has proactively developed QPIs
• First systematic population analysis of the ACR
  QPIs in a large RA cohort

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Conclusions

• EHR has data limitations - need structured data
  elements and additional programming or
  specialized software
• RA management measures scored high
• Variability noted but easily categorized and
  addressable
• Next step use redesign methodology to seek the
  highest level of rheumatologic care

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Acknowledgments

• Arthritis Foundation Grant Support