Quality of care in rheumatic diseases: performance measures and improvement

Patterns of Care Among Patients Referred to Rheumatologists in Ontario, Canada

OBJECTIVE

Our aim was to characterize referrals to rheumatologists, the early care management of patients with rheumatic diseases, and timeliness of care and treatment.

METHODS

We conducted a retrospective observational study involving patients with first-time rheumatology referrals between 2000 and 2013 in the primary care Electronic Medical Record Administrative data Linked Database (EMRALD) in Ontario, Canada. Referrals were characterized in terms of diagnoses, patient demographics, diagnostic tests, treatment initiated by family physicians and rheumatologists, and other specialists seen prior to rheumatology consultation. Timeliness of referrals, rheumatologist consultations, and treatment were determined overall and for each diagnostic category.

RESULTS

Among 2,430 patients referred to a rheumatologist, 69% were female, with an average age of 53 years. The principal diagnosis associated with the referral included osteoarthritis (32%), systemic inflammatory rheumatic diseases (31%), regional musculoskeletal conditions (16%), chronic pain conditions (14%), osteoporosis (2%), and other/miscellaneous (5%). Family physicians most frequently prescribed nonsteroidal antiinflammatory drugs/cyclooxygenase 2 inhibitors (38%), and their pre-referral diagnostic testing practice varied considerably. The duration of time from symptom onset to rheumatology consultation varied by diagnoses, with the shortest being for patients with systemic rheumatic diseases; for rheumatoid arthritis (RA), the median time to consultation was 327 days. Most of the delay occurred prior to referral; 36% of RA patients initiated a disease-modifying antirheumatic drug within 6 months of symptom onset.

CONCLUSION

Approximately 1 in 3 referrals to rheumatologists were for a systemic inflammatory rheumatic disease. We observed substantial delays to rheumatology consultations and variations in patterns of care that could be amenable to quality improvement interventions.

Incentives in Rheumatology: the Potential Contribution of Physician Responses to Financial Incentives, Public Reporting, and Treatment Guidelines to Health Care Sustainability

Concerns about the sustainability of current health care expenditure are focusing attention on the cost, quality and value of health care provision. Financial incentives, for example pay-for-performance (P4P), seek to reward quality and value in health care provision. There has long been an expectation that P4P schemes are coming to rheumatology. We review the available evidence about the use of incentives in this setting and provide two emerging examples of P4P schemes which may shape the future of service provision in rheumatology. Currently, there is limited and equivocal evidence in rheumatology about the impact of incentive schemes. However, reporting variation in the quality and provision of rheumatology services has highlighted examples of inefficiencies in the delivery of care. If financial incentives can improve the delivery of timely and appropriate care for rheumatology patients, then they may have an important role to play in the sustainability of health care provision.

Trying to improve care: the Morbidity and Mortality Conference in a division of rheumatology

OBJECTIVE

To describe the frequency and types of reported adverse events and system improvement recommendations in the Morbidity and Mortality Conference (M&MC) within the Division of Rheumatology at The Hospital for Sick Children, Toronto, Ontario, Canada (SickKids).

METHODS

A 5-year retrospective review of the M&MC within the Division of Rheumatology at SickKids was completed. Descriptive data including the number and types of events reported were collected. Events were categorized using an adaptation of the National Coordinating Council for Medication Error Reporting and Prevention Index. Recommendations were classified according to the Institute for Safe Medication Practices Canada.

RESULTS

Between January 2007 and December 2011, 30 regularly scheduled M&MC were held. Eighty-three cases were reviewed. The most common types of reported events were related to "miscommunication" (34.9%), "treatment/test/procedure" (22.9%), "adverse drug reactions" (12.0%), and "medication errors" (8.4%). Category A events ("an event that has the capacity to cause error") were the most common with 39.8% of the cases, followed by Category C events ("an event occurred that reached the patient, but did not cause harm") with 28.9%. Eighty-nine recommendations were made. Over half of these were classified as "information" (58.4%), followed by 11 "rules and policies" recommendations (12.4%). Of the 36 action items generated from these recommendations, most are either complete or ongoing.

CONCLUSION

The M&MC within the Division of Rheumatology reviews a variety of events. Increased reporting of adverse events can lead to system improvements, and has the potential to improve and promote safer healthcare.

Aggregate health burden and the risk of hospitalization in older persons post hip replacement surgery

BACKGROUND

We sought to understand the association between aggregate health burden-chronic conditions, functionally limiting health problems and mental well-being-and the likelihood of hospitalization among older persons post hip replacement surgery.

METHODS

Eight hundred and twenty-eight Medicare recipients from three U.S. states completed a questionnaire 3 years postsurgery. Using administrative data (Medicare Provider Analysis and Review), participants were prospectively followed for 12 months postquestionnaire to capture hospitalizations. Using logistic regression, demographic, socioeconomic, and behavioral characteristics and medical comorbidities were considered as predictors. Subsequently, musculoskeletal (MSK) functional and geriatric problems were added as predictors, then mental well-being and activity limitations. Path analysis was employed to elucidate interrelationships between these predictors, investigating whether mediated effects through mental well-being and activity limitations were operational.

RESULTS

Mean age was 76 years (range: 67-96); 63% were women; 23% had ≥1 hospitalization(s). When medical comorbidity, MSK limitations, and geriatric problems were considered, each was independently associated with hospitalization (odds ratios: 1.3, 1.1, 1.2, respectively). When mental well-being and activity limitations were added, these variables were predictive of hospitalization (odds ratios: 1.2, 1.1, respectively), while MSK limitations and geriatric problems were no longer predictive. Path analysis results suggested that the influence of medical comorbidity and MSK and geriatric problems were mediated through mental well-being and activity limitations.

CONCLUSIONS

Several health domains predict hospitalization, beyond and including medical comorbidity. Efforts aimed at delaying/minimizing hospitalizations in this population should consider an array of domains for potentially targeted intervention. These findings can serve as a baseline against which future research can assess the impact of changes to the health care system.

The uses of disease activity scoring and the physician global assessment of disease activity for managing rheumatoid arthritis in rheumatology practice

OBJECTIVE

To evaluate the uses of quantitative disease activity scoring and a physician global assessment of disease activity for managing rheumatoid arthritis (RA) in rheumatology practice.

METHODS

The Global Arthritis Score (GAS) and a physician global assessment (Physician Global) were determined during each office visit for a community practice RA population. The GAS was calculated from patients' self-reported pain, functional assessment, and tender joint count. The Physician Global was recorded on a 10-point visual analog scale. The correlation of these 2 disease activity measures was determined for the most recent office visit of 185 patients with RA, and the reasons for discordant results were identified by chart review.

RESULTS

The GAS and Physician Global were concordant for active or inactive disease in 126 of 185 patients (68%) and were discordant in 59 (32%). Forty-five of these discordant patients had a high GAS while their Physician Global indicated inactive disease. Their GAS values were high because of osteoarthritis, back pain, soft tissue rheumatism, and/or prior joint damage rather than active RA. The other 14 patients had a low GAS with an uncontrolled Physician Global for a variety of reasons.

CONCLUSION

(1) An RA disease activity score and a quantitative Physician Global can be measured during rheumatology office visits to document patients' disease status. (2) Disease activity scoring contributes valuable information, but should not replace the Physician Global in guiding RA patient management or reimbursement decisions.

Quality improvement in pediatric rheumatology: what do we need to do?

PURPOSE OF REVIEW

Quality improvement is a mandate for all individuals and institutions in medicine. Quality improvement has spread to the specialty certifying boards, resident education accreditation, licensure boards, and hospital medical staff offices. This review summarizes the thrust of quality improvement, provides justification for the conduct of quality improvement work, and reviews the progress in development of quality measures in rheumatology to date.

RECENT FINDINGS

The American College of Rheumatology, quality of care, and quality measure committees have developed quality indicators for rheumatoid arthritis, gout, osteoporosis, and drug safety. Pediatric rheumatology is charged with developing quality measures for juvenile idiopathic arthritis; thus, there is a commitment to improve the processes and patient outcomes. Quality improvement science has progressed over the last decade and employs methodology that utilizes small number and rapid improvement cycles. Examples of this quality improvement methodology are elaborated in this review.

SUMMARY

The review summarizes the history and current mandates for quality improvement in the medical community, progress made in the development of quality measures for adult rheumatologic conditions, and preliminary quality measures for juvenile idiopathic arthritis, and cites examples of quality improvement in progress in the pediatric rheumatology.