Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.


Rheumatoid Arthritis Quality Measure BundleDevelopment and Implementation.

Walker1,  Chad P., Newman1,  Eric D., Ayoub2,  William T., Pugliese3,  David M., Barrett1,  Jeffrey M., Mealia1,  Shea, Bili1,  Androniki

Geisinger Medical Center, Danville, PA
Geisinger Medical Group, State College, PA
Geisinger Specialty Clinic, Wilkes-Barre, PA

Background/Purpose:

Rheumatoid arthritis (RA) is associated with significant morbidity and mortality. The main cause of death is cardiovascular disease (CVD). We developed an RA quality measure bundle to identify care gaps that will allow improvement in population management.

Methods:

Using American College of Rheumatology published guidelines, pertinent literature, and team meetings with primary care and Rheumatology, we reached consensus on a core bundle of quality measures for which our Rheumatology group would be attributable. The RA bundle has three areas of focus: disease activity, medication safety and comorbidity measures (Table 1). LDL was chosen as the comorbidity measure due to association of hyperlipidemia with CVD. The US Preventive Services Task Force recommendations for the general population were used (LDL level <130 mg/dl unless indications for lower levels for secondary CVD prevention). Data were extracted from the electronic medical record and specifically developed software that allows routine electronic capture of a composite disease activity measure (CDAI - Clinical Disease Activity Index). CDAI >10 was defined as active and <=10 as not active RA.

Results:

The baseline RA bundle results are displayed in Table 2. As expected, high percentages were noted in RA on DMARD (85%) – even higher when the measure was limited to active RA on DMARD (90%). However, lower scores were seen with % of RA patients with low disease activity–61% in patients where a CDAI was available, and 28% with the most conservative measure (no CDAI available = low disease activity not achieved). Safety measures showed some opportunity (54–73%). Comorbidity measures showed excellent baseline measurement (91% had LDL checked) but opportunity for improvement in the actual measurement goal (76% had LDL within goal).

Table 1. Measure Definitions

Disease Activity Measures
RA* on DMARDDMARD on active drug list
Active RA on DMARDCDAI done and >10, then on DMARD
RA at low disease activity**CDAI done and <= 10
Medication Safety Measures
PPD if on BiologicIf on biologic, PPD ever done?
Influenza Vaccine per RecommendationsYearly unless contraindications
Pneumococcal Vaccine per RecommendationsPer 2008 ACR recommendations
Comorbidity Measures
LDL checkedChecked within 5 years if age > 45
LDL < 130LDL < 130 within 5 years
RA = Rheumatoid Arthritis, DMARD = Disease Modifying Anti Rheumatic Drug, CDAI = Clinical Disease Activity Index, PPD = Purified Protein Derivative, ACR = American College or Rheumatology, LDL = Low Density Lipoprotein
* RA population defined as 714.0 encounter diagnosis and at least 1 visit to a rheumatology department over the past 12 months
** CDAI <= 10

Table 2. Baseline Measure Achievements

 Population (n)Applicable% Meeting Metric
Disease Activity Measures
RA* on DMARD1409166385
Active RA on DMARD26028890
RA at low disease activity**460166328
(RA with CDAI measured) (749)(61)
Medication Safety Measures
PPD if on Biologic41456573
Flu Vaccine Yearly1080166365
Pneumococcal Vaccine if applicable903166354
Comorbidity Measures***
LDL checked64170591
LDL < 13053770576
RA = Rheumatoid Arthritis, DMARD = Disease Modifying Anti Rheumatic Drug, CDAI = Clinical Disease Activity Index, PPD = Purified Protein Derivative, CDC = Center for Disease Control and Prevention, LDL = Low Density Lipoprotein  
* RA population defined as 714.0 encounter diagnosis and at least 1 visit to a rheumatology department over the past 12 months  
** CDAI <= 10  
*** Population limited to patients with providers within the health system  

Conclusion:

This is the first report of a RA quality measure bundle for which a Rheumatology department has agreed to be held accountable. We have developed the ability to capture these measures electronically, including measures which are more difficult to measure and achieve, yet far more important to achieve better outcomes (i.e. % of RA at low disease activity, not just % on DMARD). Opportunities were found to improve data measurement gaps (e.g. greater capture of a CDAI value) and quality care gaps (e.g. e.g. vaccine rate). Capturing patient and physician data systematically allows identification of care gaps in RA population management. Next steps include internal discussion of the bundle results and focusing on care process redesign to improve these gaps.

To cite this abstract, please use the following information:
Walker, Chad P., Newman, Eric D., Ayoub, William T., Pugliese, David M., Barrett, Jeffrey M., Mealia, Shea, et al; Rheumatoid Arthritis Quality Measure BundleDevelopment and Implementation. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :755
DOI:

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