Methods to develop arthritis and osteoporosis measures: a view from the National Committee for Quality Assurance (NCQA).

OBJECTIVE: Performance measurement at various levels of the health care system promotes improved processes that can result in the provision of more consistent and effective care. This chapter articulates the methodology and criteria utilized in measures development to ensure accountability and serve the information needs of physicians, health care systems, health plans and consumers, using arthritis and osteoporosis as example conditions. METHODS: Observational studies conducted to assess the validity and feasibility of performance measures focused on arthritis and osteoporosis. Clinical expert panels were convened to develop measure specifications based on guidelines and evidence supporting critical aspects of care. The aspects of care that were assessed included: DMARD utilization for patients with rheumatoid arthritis; appropriate gastrointestinal prophylaxis for patients utilizing NSAIDS; comprehensive osteoarthritis care; comprehensive symptom assessment and medical management of woman over 65 years who experienced a bone fracture. RESULTS: The implementation of performance measures for key aspects of arthritis and osteoporosis care is challenged by the availability of administrative data. However, potential for improvement is evident in each of the areas studied. CONCLUSION: The key challenge to the feasibility of arthritis performance measures is the lack of administrative data to identify the eligible population. Administrative data capture suffers as a result of under-coding and under-recognition of arthritis. Consensus around a single set of measures creates a powerful tool for focusing on key components of care as a basis for quality improvement and allows for a valid comparison of care within and across health care settings.

Assessment of American College of Rheumatology quality criteria for rheumatoid arthritis in a pre-quality criteria patient cohort.

OBJECTIVE: To evaluate the American College of Rheumatology (ACR) starter set of quality measures for rheumatoid arthritis (RA) in an actual patient cohort that preceded publication of the quality measures. METHODS: We retrospectively applied the 2006 ACR quality criteria to a prospectively studied cohort of 568 patients with RA treated by 1,932 unique physicians including 255 different rheumatologists between the years 1999 and 2003. Data on performance were obtained from self-report surveys and medical record review within 12 months. RESULTS: At least 1 joint examination was performed in 98% of patients. Patient and physician global assessments were reported for 79% and 74% of patients, respectively. A total of 85% of patients received disease-modifying antirheumatic drugs (DMARDs). DMARD adjustments were made for 50% of patients in whom increasing disease activity was noted at least once and for 64% of patients in whom increasing disease activity was noted during 2 (of 4) 3-month periods within the year. Compared with self-report surveys, medical records substantially underreported performance on quality measures. CONCLUSION: The ACR-endorsed quality measures for RA can be assessed using available data sources. When both self-report and medical record data are used, adherence rates, designed to serve as minimum standards of care, were moderate or high for most measures. Prior to using indicators to compare quality across groups, specific strategies for operationalizing measures and for using accurate data sources to assess adherence to the measures should be defined.

Application of explicit process of care measurement to rheumatoid arthritis: Moving from evidence to practice.

OBJECTIVE: To construct quality measures with measurement validity and meaning for clinicians. METHODS: We conducted a prospective cohort study of rates of change in disease-modifying antirheumatic drug (DMARD) and/or systemic corticosteroid drug or dose for 568 patients with rheumatoid arthritis (RA) across 6,159 clinical encounters within 12 months to examine how changes in clinical specifications change adherence. RESULTS: Rates of DMARD change were sensitive to specifications regarding the intensity of disease activity (severe or moderate), duration of specified disease activity, and length of the observation period. Over 12 months, the proportions of 377 patients with severe disease activity observed for 1-month, 2-month, and 3-month time blocks who had a change in DMARD drug or dose were 36%, 57%, and 74%, respectively. Over 12 months, a change in DMARD drug or dose was observed for 44%, 50%, and 68% of 377 patients with severe disease within 3 months, 6 months, and 12 months, respectively, of the patient meeting criteria for severe disease activity. A change in DMARD drug or dose was observed for 21%, 23%, and 34% of 149 patients with moderate disease activity within 3, 6, and 12 months, respectively, of the patient meeting criteria for moderate disease activity. CONCLUSION: Rates of pharmacologic interventions for patients with moderate and severe RA disease activity vary substantially by intensity and duration of disease activity and by duration of period for observing change. Lack of precision in explicit process criteria could substantially mislead comparisons of quality of care across comparison groups.

Evaluating the quality of care in rheumatic diseases.

An understanding of the level of health care quality and the factors that affect it is necessary for providers and insurers to optimize health outcomes for patients and should be carefully considered when making decisions about resource allocation. Additionally, information about health care quality can be used by patients and others to inform decisions about the purchase of health care. Although much work has been done to characterize the quality of health care, little is known about the quality of care for the rheumatic diseases. This paper reviews what is known about health care quality for these diseases.

The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community.

OBJECTIVES: To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey. DESIGN: Analysis of longitudinal survey data. SETTING: A nationally representative community-based survey. PARTICIPANTS: Six thousand two hundred five Medicare beneficiaries age 65 and older. MEASUREMENTS: Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline. RESULTS: A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of >or=3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of.78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system. CONCLUSIONS: A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

Quality of care for patients with rheumatoid arthritis.

CONTEXT: Patients with rheumatoid arthritis are at risk for substantial morbidity because of their arthritis and premature mortality due to comorbid diseases. However, little is known about the quality of the health care that these patients receive. OBJECTIVE: To assess the quality of the health care that rheumatoid arthritis patients receive for their arthritis, comorbid diseases, and health care maintenance and to determine the effect of patterns of specialty care on quality. DESIGN, SETTING, AND PARTICIPANTS: Historical cohort study of 1355 adult rheumatoid arthritis patients enrolled in the fee-for-service or discounted fee-for-service plans of a nationwide US insurance company. Patients were identified and followed up through administrative data between 1991 and 1995. MAIN OUTCOME MEASURES: Quality scores for arthritis, comorbid disease, and health care maintenance were developed from performance on explicit process measures that related to each of these domains and described the percentage of indicated health care processes performed within each domain during each person-year of the study. RESULTS: During 4598 person-years of follow-up, quality scores were 62% (95% confidence interval [CI], 61%-64%) for arthritis care, 52% (95% CI, 49%-55%) for comorbid disease care, and 42% (95% CI, 40%-43%) for health care maintenance. Across domains, care patterns including relevant specialists yielded performance scores 30% to 187% higher than those that did not (P<.001) and 45% to 67% of person-years were associated with patterns of care that did not include a relevant specialist. Presence of primary care without specialty care yielded health care maintenance scores that were 43% higher than those for patterns that included neither primary nor relevant specialty care (P<.001). CONCLUSIONS: In this population, health care quality appears to be suboptimal for arthritis, comorbid disease, and health care maintenance. Patterns of care that included relevant specialists were associated with substantially higher quality across all domains. Patterns that included generalists were associated with substantially higher quality health care maintenance than patterns that included neither a generalist nor a relevant specialist. The optimal roles of primary care physicians and specialists in the care of patients with complex conditions should be reassessed. JAMA. 2000;284:984-992

Selecting target conditions for quality of care improvement in vulnerable older adults.

OBJECTIVE: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults. DESIGN: Discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews. METHODS: A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community-dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions. RESULTS: The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end-of-life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community-dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end-of-life care) are not recorded as diagnoses. CONCLUSIONS: Twenty-one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings.

Medical resource use and costs among rheumatoid arthritis patients receiving disease-modifying antirheumatic drug therapy.

OBJECTIVE: To identify costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drug (DMARD) therapies. METHODS: Using managed care organization data, we identified members who (a) were prescribed any DMARD therapy for two consecutive months between July 1993 and February 1998, (b) were aged > or = 18 years, (c) had > or = 6 months of DMARD-free enrollment prior to the first DMARD, and (d) had a diagnosis of RA. RESULTS: The average age of the cohort (n = 571) was 51 years, and 70% were women. Mean duration of enrollment following initiation of DMARD therapy (observation period) was 19.5 months; 28.8% of patients switched DMARD regimens. The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. Monthly RA-coded costs varied by DMARD: hydroxychloroquine $227 (n = 252), methotrexate $340 (n = 185); sulfasalazine $233 (n = 49), and other mono/combination therapy $425 (n = 85) (P = 0.001). CONCLUSION: Costs of RA-coded care in patients receiving DMARDs are low and vary by DMARD.

Costs attributable to osteoarthritis.

OBJECTIVE: To estimate charges attributable to osteoarthritis (OA) in a managed care organization. METHODS: Longitudinal study based on insurance claims incurred and filed between 1991 and 1993 in a national managed care organization. Patients with claims for OA were randomly sampled to yield 20,000 study subjects. Charges per person-year were determined for these patients and compared to those of comparison subjects matched for age, sex, and insurance plan without claims for OA. RESULTS: Total charges per patient-year adjusted to 1993 dollars for patients with OA <65 and > or =65 years of age were $5,294 and $5,704, respectively, while charges for controls were $2,467 and $3,741, respectively. Thus, charges due to OA were $2,827 and $1,963, accounting for 5% of total plan charges. CONCLUSION: Patients with symptomatic OA incur charges for medical care at about twice the rate of plan enrollees without claims for OA and account for a substantial proportion of total charges in a managed care plan.