American College of Rheumatology quality indicators for rheumatoid arthritis: benchmarking, variability, and opportunities to improve quality of care using the electronic health record.

OBJECTIVE: To measure how rheumatologists across our health system performed with the American College of Rheumatology (ACR) quality indicators (QIs) for rheumatoid arthritis (RA) and methotrexate (MTX) drug safety, and to develop opportunities for improvement. METHODS: An electronic health record (EHR) review of 1,062 unique RA patients seen by 15 rheumatologists in a 1-year period was performed. Percentage of each QI met, reasons why the metric was not met, and performance of rheumatologists based on years of experience were evaluated. RESULTS: The percentage met was high for QI-2 (RA disease-modifying antirheumatic drug use; 94%), QI-3 (intervention if RA worse; 85%), and QI-4 (MTX risks discussion; 87%). Percentage met was lower for QI-1 (RA core data set; 69%), QI-5 (MTX baseline studies; 41%), and QI-6 (MTX followup studies; 46%). QI-1 and QI-5 were low due to most physicians missing a single test, and QI-6 was low because of few physicians driving the percentage down. Better QI performance was seen in rheumatologists with 10 years of experience for QI-1 (90% versus 64%; odds ratio [OR] 4.21, P = 0.004) and QI-3 (96% versus 82%; OR 4.47, P = 0.019). EHR chart review for this population required 179.3 hours. CONCLUSION: Measurement allows us to better understand the quality of care that we deliver. In this systematic benchmarking of the ACR QIs in a large RA cohort, performance was excellent in RA treatment-related QIs. Significant variability was noted in RA and MTX monitoring measures, which can be addressed using process redesign techniques.

Hereditary angioedema in a family presenting as transient periarthritis.

Hereditary angioedema (HAE) is a rare condition known to cause episodic, self-limiting, nonpruritic, nonpitting edema that involves skin and visceral organs. It may affect any external body surface including face, extremities, and genitalia. Most commonly involved viscera are gastrointestinal and respiratory systems. Patients may have severe abdominal pain because of edema of the bowel wall. This disease can cause life threatening laryngeal edema if it involves the airway.We describe a patient with HAE who was initially diagnosed with arthritis after she had recurrent edema around her peripheral joints. Diagnosis of HAE in her led to the same diagnosis in her sister and her father. HAE should be considered in the differential diagnosis of recurrent attacks of periarticular swelling.

Local and disseminated infections caused by Mycobacterium marinum: an unusual cause of subcutaneous nodules.

Mycobacterium marinum is a free-living, nontuberculous, photochromogenic mycobacterium, which can cause opportunistic infections in humans. It can cause infection through the skin that has undergone minor trauma, as the portal of entry from contaminated water, fish tanks and nonchlorinated swimming pools. It can cause skin lesions, which are either single, papulonodular lesions, confined to an extremity or may resemble cutaneous sporotrichosis. This infection can also cause deeper infections including tenosynovitis, bursitis, arthritis, and osteomyelitis. Disseminated infections and visceral involvements have been reported in immunocompromised patients. We describe 3 patients seen in Geisinger Medical Center from 2000 to 2005 in whom the diagnosis of M. marinum infection was made. All 3 patients described had sporotrichoid nodular lesions, one had a preceding minor trauma, one was initially misdiagnosed as having rheumatoid arthritis and developed disseminated infection requiring prolonged treatment, and one had direct exposure to fish and fish tank. M. marinum infection is frequently misdiagnosed probably due to its rarity of occurrence, indolent presentation and difficulty in isolation and culture. Recognition depends on a high index of suspicion and eliciting a history of aquatic exposure. Diagnosis usually requires tissue biopsy for histopathologic examination and culture.

Misdiagnosis of a chylous cyst as chest wall gouty tophus: a case of true pseudogout.

A patient referred to us for recurrent chest wall gouty tophus, but who was determined to actually have a chylous cyst, is described herein. Chylous cysts of the neck or chest wall can be caused by thoracic duct injury. Chyle contains 4-40 gm/liter of lipids, mostly triglycerides, and these can form birefringent crystals upon drying, leading to a false diagnosis of gout.