©2004 by the National Committee for
Quality Assurance
Sarah Sampsel, MPH
National Committee for Quality
Assurance
AcademyHealth 2004

• 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

• Assess Desirable Attributes (HEDIS
®
)
(selected)
– Feasibility: barriers to implementation
– Validity: age limits, exclusions, diagnoses
– ‘Actionability’: variation in performance across plans and geographic regions

•
•
•

• % 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)

Arthritis symptom assessment: documentation of assessment of pain and functional status
Diagnosis Arthritis
Prevelance/1000
Pain
Assessment
Functional
Assessment
OA
RA
Other
Inflammatory
C = 1.8
M+C = 14.1
Md = 0.2
C = 1.4
M+C = 7.3
Md = 0.2
C = 0.3
M+C = 0.7
Md = 0.0
82.9%
77.0%
67.0%
C = Commercial; M+C = Medicare + Choice; Md = Medicaid
56.1%
57.7%
55.3%

Osteoarthritis care: documentation of recommendations for weight loss and physical activity, acetaminophen use
Plan Weight
Loss*
Physical
Activity
Acetaminophen
A 33.3% 41.2%
A – Medicare 35.0% 22.2%
16.7%
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

Appropriate gastrointestinal prophylaxis for high risk patients utilizing prescription NSAIDs
A
A
B
Plan
– M+C
% Adult Members with NSAID Rx
11.9%
26.0%
12.2%
% high risk patients with GI prophylaxis
22.6%
14.3%
34.2%
C 13.5% 40.8%
C – Md 5.3% 35.3%
C = Commercial; M+C = Medicare + Choice; Md = Medicaid

Disease Modifying Anti-Rheumatic Drug (DMARD)
Therapy in Rheumatoid Arthritis
Plan RA
Prevalence/1000
A C = 0.8
M+C = 5.4
Commercial Medicaid Medicare
67.6% N/A 71.4%
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

• 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

• 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

• 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

• 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

• 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.