Measuring quality in arthritis care: The Arthritis Foundation's quality indicator set for analgesics

Identification of Five Quality Needs for Rheumatology (Text Analysis and Literature Review)

Background: While the use of the term "quality" in industry relates to the basic idea of making processes measurable and standardizing processes, medicine focuses on achieving health goals that go far beyond the mere implementation of diagnostic and therapeutic processes. However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. Screening and content evaluation were carried out using the PRISMA-P 2015 checklist. After duplicate search in the Endnote reference management software (version X9.1), the software Rayyan QCRI (https://rayyan.qcri.org) was applied to check for pre-defined inclusion and exclusion criteria. Abstracts and full texts were screened and rated using Voyant Tools (https://voyant-tools.org/). Key issues were identified using the collocate analysis. Results: The number of selected publications was small but specific (14 relevant correlations with coefficients >0.8). Using trend analysis, 15 publications with relative frequency of keywords >0.0125 were used for content analysis, revealing 5 quality needs. The treat to target (T2T) initiative was identified as fundamental paradigm. Outcome parameters required for T2T also allow quality assessments in routine clinical work. Quality care by multidisciplinary teams also focusing on polypharmacy and other quality aspects become essential, A global software platform to assess quality aspects is missing. Such an approach requires reporting of multiple outcome parameters according to evidence-based clinical guidelines and recommendations for the different rheumatic diseases. All health aspects defined by the WHO (physical, mental, and social health) have to be integrated into the management of rheumatic patients. Conclusion: For the future, quality projects need goals defined by T2T based initiatives in routine clinical work, secondary quality goals include multidisciplinary cooperation and reduction of polypharmacy. Quality indicators and standards in different health systems will provide new information to optimize patients' care in different health systems.

Design, recruitment outcomes, and sample characteristics of the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial

This manuscript describes the study protocol, recruitment outcomes, and baseline participant characteristics for the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) trial. SPACE is a pragmatic randomized comparative effectiveness trial conducted in multiple VA primary care clinics within one VA health care system. The objective was to compare benefits and harms of opioid therapy versus non-opioid medication therapy over 12months among patients with moderate-to-severe chronic back pain or hip/knee osteoarthritis pain despite analgesic therapy; patients already receiving regular opioid therapy were excluded. Key design features include comparing two clinically-relevant medication interventions, pragmatic eligibility criteria, and flexible treat-to-target interventions. Screening, recruitment and study enrollment were conducted over 31months. A total of 4491 patients were contacted for eligibility screening; 53.1% were ineligible, 41.0% refused, and 5.9% enrolled. The most common reasons for ineligibility were not meeting pain location and severity criteria. The most common study-specific reasons for refusal were preference for no opioid use and preference for no pain medications. Of 265 enrolled patients, 25 withdrew before randomization. Of 240 randomized patients, 87.9% were male, 84.1% were white, and age range was 21-80years. Past-year mental health diagnoses were 28.3% depression, 17% anxiety, 9.4% PTSD, 7.9% alcohol use disorder, and 2.6% drug use disorder. In conclusion, although recruitment for this trial was challenging, characteristics of enrolled participants suggest we were successful in recruiting patients similar to those prescribed opioid therapy in usual care.

Rheumatologists' perception of systemic lupus erythematosus quality indicators: significant interest and perceived barriers

Differences in quality of care may contribute to health disparities in systemic lupus erythematosus (SLE). Studies show low physician adherence rates to the SLE quality indicators but do not assess physician perception of SLE quality indicators or quality improvement. Using a cross-sectional survey of rheumatologists in the southeastern USA, we assessed the perception and involvement of rheumatologists in quality improvement and the SLE quality indicators. Using electronic mail, an online survey of 32 questions was delivered to 568 rheumatologists. With a response rate of 19% (n = 106), the majority of participants were male, Caucasian, with over 20 years of experience, and seeing adult patients in an academic setting. Participants had a positive perception toward quality improvement (81%) with a majority responding that the SLE quality indicators would significantly impact quality of care (54%). While 66% of respondents were familiar with the SLE quality indicators, only 18% of respondents reported using them in everyday practice. The most commonly reported barrier to involvement in quality improvement and the SLE quality indicators was time. Rheumatologists had a positive perception of the SLE quality indicators and agreed that use of the quality indicators could improve quality of care in SLE; however, they identified time as a barrier to implementation. Future studies should investigate methods to increase use of the SLE quality indicators.

Quality indicators for physiotherapy care in hip and knee osteoarthritis: development and clinimetric properties

OBJECTIVE

The aim of the present study was to develop process quality indicators for physiotherapy care based on key recommendations of the Dutch physiotherapy guideline on hip and knee osteoarthritis (OA).

METHODS

Guideline recommendations were rated for their relevance by an expert panel, transformed into potential indicators and incorporated into a questionnaire, the Quality Indicators for Physiotherapy in Hip and Knee Osteoarthritis (QIP-HKOA). Adherence with each indicator was rated on a Likert scale (0 = never to 4 = always). The QIP-HKOA was administered to groups of expert (n = 51) and general (n = 134) physiotherapists (PTs) to test its discriminative power. Reliability was tested in a subgroup of 118 PTs by computing the intraclass correlation coefficient (ICC). QIP-HKOA items were included if they were considered to be related to the cornerstones of physiotherapy in hip and knee OA (exercises and education), had discriminative power and/or if they were followed by <75% of PTs in both groups.

RESULTS

Nineteen indicators were derived from 41 recommendations. Twelve indicators were considered to be the cornerstones of physiotherapy care; six indicators had discriminative power and/or were followed by <75% PTs in both groups, resulting in an 18-item QIP- HKOA. The QIP-HKOA score was significantly higher with expert [60.73; standard deviation (SD) 5.67] than with general PTs (54.65; SD 6.17) (p < 0.001). The ICC of the QIP-HKOA among 46/118 PTs was 0.89.

CONCLUSION

The QIP-HKOA, based on 18 process indicators derived from a physiotherapy guideline on hip and knee OA was found to be reliable and discriminated between expert and general PTs. Its ability to measure improvement in the quality of the process of physiotherapy care needs to be further examined.

Patient-reported quality of care for osteoarthritis: development and testing of the osteoarthritis quality indicator questionnaire

OBJECTIVE

To develop and test a new instrument for patient self-reported quality of osteoarthritis (OA) care, and to provide quality indicator (QI) pass rates in a Norwegian OA cohort.

METHODS

The OsteoArthritis Quality Indicator (OA-QI) questionnaire was developed using published QIs, expert panels, and patient interviews. Self-reported data were collected from 359 persons in a Norwegian OA cohort, and test-retest reliability and validity were assessed. Separate QI pass rates and summary QI pass rates were calculated.

RESULTS

The 17-item questionnaire includes QIs related to patient education and information, regular provider assessments, referrals, and pharmacologic treatment. The patient self-reported questionnaire was completed with minimal respondent burden. Support for content validity was confirmed by 2 patient research partners and 2 expert panels. All 10 predefined hypotheses relating to construct validity were confirmed. Test-retest kappa coefficients ranged from 0.20-0.80 and the percentage of exact agreement ranged from 62-90%. The mean pass rate for individual QIs was 31% (range 5-49%). The median summary QI pass rate was 27% (interquartile range 12-50%), with lower summary pass rates for nonpharmacologic compared to pharmacologic treatments.

CONCLUSION

To our knowledge, this is the first instrument developed to measure patient-reported QI pass rates for OA care. This study indicates that the OA-QI questionnaire is acceptable to persons with OA, and its short format makes it suitable for population surveys. The low patient self-reported QI pass rates in this study suggest a potential for quality improvement in OA care.

Quality indicators for inflammatory bowel disease: development of process and outcome measures

INTRODUCTION

Variation in adherence to management guidelines for inflammatory bowel disease (IBD) suggests variable quality of care. Quality indicators (QIs) can be developed to measure the structure, processes, and outcomes of health care delivery. The RAND/UCLA appropriateness method was used to develop a set of process and outcome QIs to define quality of care for IBD.

METHODS

Guidelines and position papers for IBD published from 2006 to 2011 were reviewed for potential QIs, which were rated by a multidisciplinary panel. Potential process and outcome QIs were discussed at 3 moderated in-person meetings, with pre-meeting and post-meeting confidential electronic voting. Panelists rated the validity and feasibility of QIs on a 1 through 9 scale; disagreement was assessed using a validated index. QIs rated above 8 were selected for the final set.

RESULTS

More than 500 potential process QIs were extracted from guidelines. Following ratings and discussion by the first panel, 35 process QIs were selected for literature review. After the second panel, 10 process QIs were included in the final set. Candidate outcome QIs were then derived from physician, nurse, and patient input and ratings, in addition to outcomes associated with candidate process QIs. None of the top QIs exhibited disagreement.

CONCLUSIONS

A set of QIs for IBD was developed with expert interpretation of the literature and multidisciplinary input. Outcome QIs focused largely on remission and quality of life, whereas process QIs were aimed at therapeutic optimization and patient safety. Evaluation of these QIs in clinical practice is needed to assess the correlation of performance on process QIs with performance on outcome QIs.

An explicit quality indicator set for measurement of quality of care in patients with cirrhosis

BACKGROUND & AIMS

Cirrhosis is a prevalent and expensive condition. With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with cirrhosis, we established a set of explicit quality indicators (QIs) for their treatment.

METHODS

We organized an 11-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for cirrhosis. We provided the panel with a report that summarized the results of a comprehensive literature review of data linking candidate QIs to outcomes. The panel performed independent ratings of each candidate QI by using a standard 9-point RAND appropriateness scale (RAS) (ranging from 1 = not appropriate to 9 = most appropriate). The panel members then met, reviewed the ratings, and voted again by using an iterative process of discussion. The final set of QIs was selected; QIs had a median RAS >7, and panel members agreed on those selected.

RESULTS

Among 169 candidate QIs, the panel rated 41 QIs as valid measures of quality care. The selected QIs cover 6 domains of care including ascites (13 QIs), variceal bleeding (18 QIs), hepatic encephalopathy (4 QIs), hepatocellular cancer (1 QI), liver transplantation (2 QIs), and general cirrhosis care (3 QIs). Content coverage included prevention, diagnosis, treatment, timeliness, and follow-up.

CONCLUSIONS

We developed an explicit set of evidence-based QIs for treatment of cirrhosis. These provide physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in any setting where care for patients with cirrhosis is provided.

Measuring quality of care in patients with nonvariceal upper gastrointestinal hemorrhage: development of an explicit quality indicator set

OBJECTIVES

With an increasing emphasis on quality in health care and recognition of inconsistencies in the management of patients with nonvariceal upper gastrointestinal hemorrhage (NVUGIH), it is critical to establish a set of explicit quality indicators (QIs) in NVUGIH.

METHODS

We conducted a nine-member, multidisciplinary expert panel and followed modified Delphi methods to systematically identify a set of QIs for NVUGIH. The panel performed independent ratings of each candidate QI using a nine-point RAND appropriateness scale, then met in person and re-voted using an iterative process of discussion. The final set comprised QIs with a median RAND Appropriateness Score >or=7 and no disagreement among experts.

RESULTS

Among 116 candidate QIs, the panel rated 26 as valid measures of quality care. The selected QIs cover pre-endoscopy, endoscopy, and post-endoscopy care, including diagnosis, early resuscitation, risk stratification, endoscopic care, Helicobacter pylori management, and proton pump inhibitor therapy.

CONCLUSIONS

We have developed an explicit set of evidence-based QIs in NVUGIH, providing physicians and institutions with a tool to identify processes amenable to quality improvement. This tool is intended to be applicable in all institutions providing care for NVUGIH patients.

Assessment of coxib utilization by rheumatologists for nonsteroidal antiinflammatory drug gastroprotection prior to the coxib market withdrawals

OBJECTIVE

To examine cyclooxygenase 2 inhibitor (coxib) utilization by rheumatologists for patients receiving nonsteroidal antiinflammatory drugs (NSAIDs) prior to the coxib market withdrawals.

METHODS

A prospective study of patients with rheumatoid arthritis enrolled in the Consortium of Rheumatology Researchers of North America registry was performed.

RESULTS

Of 1,833 patients receiving prescription NSAIDs, 1,380 (75.3%) received gastroprotection, defined as either coxib monotherapy and/or gastroprotective agent (GPA) cotherapy, and 1,207 (65.8%) received coxibs. The distribution of gastroprotective strategies included 860 (46.9%) patients who were prescribed coxib monotherapy, 347 (18.9%) prescribed dual coxib plus GPA cotherapy, 173 (9.4%) prescribed a nonselective NSAID (NS-NSAID) plus GPA cotherapy, and 453 (24.7%) prescribed an NS-NSAID without GPA cotherapy. For patients with 0, 1, and > or =2 identifiable gastrointestinal (GI) risk factors, coxib prescribing rates as a proportion of NSAID agents were 64.1%, 66.4%, and 68.6%, respectively; among dual aspirin/NSAID users, coxib prescribing rates were 66.2%, 78.3%, and 68.5% of NSAID prescriptions, respectively.

CONCLUSION

The majority of NSAID users were prescribed a gastroprotective strategy, primarily attributable to coxib utilization. Coxib utilization rates were consistently high across all levels of GI risk, including patients without identifiable risk factors. These data indicate that rheumatologists broadly adopted the coxib class of NSAIDs in a nonselective manner with respect to underlying GI risk and concomitant aspirin use. As novel therapeutic classes are introduced, early evaluation of prescribing patterns using arthritis registries can determine the appropriateness of prescribing patterns and may improve patient outcomes.

Quelles informations délivrer au patient sur le risque cardiovasculaire et rénal des AINS?

OBJECTIVE

Patient information is a topical subject. The aim of this review is to present the rare studies concerning the degree of patient information on the cardiovascular and renal risks of the non-steroidal anti-inflammatory drugs and to suggest some recommendations on this subject.

METHODOLOGY

After analysis of the literature (Medline search - January 2006), a series of recommendations has been drawn up following discussion among experts from different specialties (clinical epidemiology, rheumatology, cardiology, nephrology, gastroenterology).

RECOMMENDATIONS

It appears necessary to warn all patients of the potential risk of hyperkalemia, renal insufficiency and/or hydrosodium retention (decompensation of an arterial hypertension or a cardiac insufficiency), especially subjects who present risk factors such as age over 75 years, a dehydration, a pre-existing renal disorder, etc. Concerning the risk of arterial thrombotic incident (coronary or cerebral), it is important to indicate that this risk is rare and seems to be observed particularly during prolonged treatments and at high dose.

Quality of care for NSAID users: development of an assessment tool

OBJECTIVE

Assessments of NSAID use based on authoritative guidelines typically overlook patients' views and nuances of medical history. Our objective was to develop an assessment tool that incorporates these aspects, and technical items, for quality of care assessments in NSAID users.

METHODS

Patients newly referred to a university hospital were interviewed by a nurse using an agreed template. A multidisciplinary group of rheumatologists, nurse specialists, primary care physicians and a pharmacist reviewed current guidance and systematic reviews on NSAID use, and a series of interview transcripts. The group agreed, by informal consensus, important determinants of effective and safe NSAID use. Technical aspects of medical care and items that reflected interpersonal care were included in an index for assessing quality of care for individual patients. Interview transcripts of 100 patients were scored by panel members and reliability of scores was tested by calculating weighted percentage agreement and the kappa statistic.

RESULTS

Our final index had five domains: medical risk factors; steps taken to reduce risk; knowledge of adverse effects; NSAID dose; and cost efficiency. Each item was scored 0, 1 or 2. Scores were summed, giving a maximum of 10 (low scores indicating low quality). Intra-rater agreement was >90%; kappa was 0.47-0.87 for individual domains and 0.59 for overall score. Inter-rater agreement for overall score was 95%; kappa was 0.25-0.78 for domains and 0.48 for overall score. Patients with especially low scores were identified using the mode of scores for five assessors; obvious clinical concerns were identified, supporting index face validity.

CONCLUSIONS

A simple index to evaluate quality of care for NSAID users based on a patient interview is described. This may be used by one or more assessors to examine care standards and highlight deficiencies in relation to NSAID use in practice.

Evidence-based rheumatology practice

PURPOSE OF REVIEW

This review is intended to update readers on recent developments in the evidence-based practice of rheumatology.

RECENT FINDINGS

Several new or updated evidence-based practice guidelines have recently emerged. In addition, a large body of evidence upon which to base practice has been addressed in the many systematic reviews and meta-analyses that have been newly published, including nine new or updated Cochrane reviews. Several studies have also investigated adherence to practice guidelines, interventions to improve clinical practice, and quality of care in the field of rheumatology in the past year.

SUMMARY

Evidence-based rheumatology is an ongoing effort, with continuing revision and update of recommendations. It may currently be used to address a wide variety of clinical questions. The initiatives on practice-based research to establish quality indicators and identify areas where rheumatology practice can be enhanced are a welcome addition to health services research in this field.

Measuring quality in arthritis care: The Arthritis Foundation's Quality Indicator set for osteoarthritis

OBJECTIVE

To develop a comprehensive set of explicit process measures to assess the quality of health care for osteoarthritis and to describe the scientific evidence that supports each measure.

METHODS

Through a comprehensive literature review, we developed potential quality measures and a summary of existing data to support or refute the relationship between the processes of care proposed in the indicators and relevant clinical outcomes. The proposed measures and literature summary were presented to a multidisciplinary panel of experts in arthritis and pain. The panel rated each proposed measure for its validity as a measure of health care quality.

RESULTS

Among 22 measures proposed for osteoarthritis, the expert panel rated 14 as valid measures of health care quality.

CONCLUSION

Sufficient scientific evidence and expert consensus exist to support a comprehensive set of measures to assess the quality of heath care for osteoarthritis. These measures can be used to gain an understanding of the quality of care for patients with osteoarthritis.