Measuring Quality of Care in People with Arthritis Sarah Sampsel, MPH National Committee for Quality Assurance ©2004 by the National Committee for Quality Assurance AcademyHealth 2004 Introduction • Arthritis and other rheumatic conditions – Leading cause of disability among adults in the United States – Early intervention could reduce chronic symptoms – Highest utilizers of NSAIDs – Often receive suboptimal care to treat symptoms – Potential for improvement with standardized measurement Objectives • Assess Desirable Attributes (HEDIS® ) (selected) – Feasibility: barriers to implementation – Validity: age limits, exclusions, diagnoses – ‘Actionability’: variation in performance across plans and geographic regions Methods • Multi-disciplinary expert panel • Volunteer testing by health plans • Abstraction from administrative and medical record data Arthritis Measures • % of patients screened for pain and functional status • % with osteoarthritis with recommendations for weight loss, physical activity, acetaminophen use • % of high risk patients using non-steroidal antiinflammatory drugs (NSAIDs) and receiving gastrointestinal prophylaxis • % of patients with rheumatoid arthritis receiving a disease modifying anti-rheumatic drug (DMARD) Principal Findings Arthritis symptom assessment: documentation of assessment of pain and functional status Diagnosis Arthritis Prevelance/1000 Pain Assessment Functional Assessment OA C = 1.8 M+C = 14.1 Md = 0.2 82.9% 56.1% RA C = 1.4 M+C = 7.3 Md = 0.2 77.0% 57.7% Other Inflammatory C = 0.3 M+C = 0.7 Md = 0.0 67.0% 55.3% C = Commercial; M+C = Medicare + Choice; Md = Medicaid Principal Findings Osteoarthritis care: documentation of recommendations for weight loss and physical activity, acetaminophen use Plan Weight Loss* Physical Activity Acetaminophen A 33.3% 41.2% 16.7% A – Medicare 35.0% 22.2% 15.1% B 57.9% 43.5% 14.0% OA Prevalence/1000 members: Commercial: 1.2; Medicare + Choice: 78.1 *Credit given for members with BMI < 27 kg/m2 and no recommendation for weight loss or those with BMI > 27 kg/m2 and a documented recommendation for weight loss Principal Findings Appropriate gastrointestinal prophylaxis for high risk patients utilizing prescription NSAIDs Plan % Adult Members with NSAID Rx 11.9% % high risk patients with GI prophylaxis 22.6% A – M+C 26.0% 14.3% B 12.2% 34.2% C 13.5% 40.8% C – Md 5.3% 35.3% A C = Commercial; M+C = Medicare + Choice; Md = Medicaid Principal Findings Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis Plan RA Commercial Medicaid Medicare Prevalence/1000 A C = 0.8 67.6% N/A 71.4% M+C = 5.4 C C = 2.1 75.8% 76.5% N/A Md = 1.1 C = Commercial; M+C = Medicare + Choice; Md = Medicaid • Only measure with potential for HEDIS inclusion • Use of Biologic DMARD Therapies <11% of prescriptions Summary of Findings • Administrative data unreliable for identification of osteoarthritis cases – Expected prevalence: 15 - 20% – Field-Test: 1% (Comm.), 8% (Medicare + C) – Potential under-coding and under-reporting • Enormous potential for improvement – Documentation of services that were provided Summary of Findings • Challenges for measure implementation – Lack of medical record documentation – Unable to locate documentation of many aspects of care measured – Inconsistency of documentation – Lack of standardized instruments to assess pain and functional status Implications • Performance measures create a powerful tool for quality improvement and delivery system comparisons • Quality of care improvement in arthritis will require better coding of diagnosis and documentation of care rendered Musculoskeletal Workgroup • Teresa Brady, PhD – CDC Arthritis Program • John Klippel, MD – Arthritis Foundation • Catherine MacLean, MD, PhD – UCLA/RAND • John Mason, PhD – BCBS of Massachusetts • Kenneth Saag, MD, MSc – University of Alabama at Birmingham, CERTS • Khaled Saleh, MD, MSc, FRCSC – Univ. of Minnesota • Daniel Solomon, MD, MPH – Brigham & Women’s Hospital • Jeffrey Susman, MD – Univ. of Cincinnati • Patricia Venus – Center for Health Care Policy and Evaluation • Neil Wenger, MD – UCLA Supported in part b y: Janssen Pharmaceutica, Merck & Company, Purdue Pharma, Pfizer Inc., Amgen Acknowledgements • Co-Authors: – Catherine MacLean, MD, PhD; RAND Health and UCLA Division of Rheumatology – Philip Renner, MBA; National Committee for Quality Assurance – Russell Mardon, PhD; National Committee for Quality Assurance • Project was a partnership between NCQA and the Arthritis Foundation, and built upon work conducted by RAND Health/University of Alabama at Birmingham: Arthritis Foundation Quality Indicator Project (AFQuIP) – MacLean CH, et al. Measuring Quality in Arthritis Care: Methods for Developing the Arthritis Foundation’s Quality Indicator Set. Arthritis Care & Research. 2004;51(2):193-202.