CRA Guidelines for the Management of
Rheumatoid Arthritis- Update
Pooneh Akhavan, MD
May 25, 2013
Learning Objectives
1- Describe the CRA's multi-faceted approach to
disseminate the RA recommendations
2- Understand the process of moving from RA
guidelines to RA Quality Indicators
2
Disclosures
• CRA recommendations were supported by the CIHR
and matched funds from the CRA
CRA Recommendations for RA Management
J Rheum 2012
CRA Recommendations for RA
 Part 1: Treatment – 26 recommendations
• RA management strategies (6)
• Glucocorticoids and traditional DMARDs (8)
• Biologic DMARDs (12)
 Part 2: RA drug safety – 13 recommendations
•Perioperative management (2)
•Screening for LTBI prior to biologic therapy (4)
•Optimal vaccination practices (3)
•Treatment of RA patients with a history of malignancy (4)
CRA Annual Meeting 2013- Ottawa
Have you read the recommendations?
1.
2.
3.
4.
Yes, read Part I: Treatment
Yes, read Part II: Safety
Yes, read both parts I and II
No
44%
43%
12%
1%
1
2
3
4
Presentation Outline
• Dissemination activities
• Moving towards the Quality Indicators
Dissemination
Overview Dissemination Activities
 Completed
1. Publications (open access J Rheum / CRA website)
2. Presentations (Local, regional, national international)
3. Additional tools for download (CRA website)
4. CRA guideline self-evaluation survey followed by CRAJ
question and answer series (Summer 2013)
 In progress
1. MDbriefcase eRecommendation program (CME accredited)
2. EMR integration
 In future
Multi-disciplinary RA guideline dissemination workshop
September 2013
1. Dissemination Activities-Completed
http://rheum.ca/en/publications/cra_ra_guidelines
Download RA
guideline
documents
Download RA
algorithms &
slide decks
Dissemination Activities-Completed
2. Presentations at rheumatology meetings:
• International: ACR, EULAR
• National: CRA, PANLAR
• Regional meetings: WAR, ORA, SOAR, Laurentian
• Various local meetings
3. Slide decks as self-teaching tools and/or for
presentations at local rounds and other educational
activities
(www.rheum.ca/en/publications/cra_ra_guidelines)
Dissemination Activities- Completed
4. CRA self-evaluation survey:
- 24 questions
- CRA membership
- April-May 2013
- 188 of 432 responded
- CRAJ series (to start this Summer)
Dissemination Activities- In Progress
1. MDbriefcase eRommendation program (will be CME accredited)
 TREATMENT
ASPECTS
 SAFETY
ASPECTS
Dissemination Activities- In Progress
2. Ongoing discussions with eHealth
Ontario
- EMR Integration of selected key recommendations
to measure performance
Dissemination Activities- In Future
•CIHR meeting grant approved
September 2013
Interdisciplinary Dissemination and Local Adaptation
Workshop (RA Guidelines)
•Objectives:
• a) Discuss barriers and local adaptation issues from
knowledge users (clinicians, therapists, pharmacists, nurses
and patients)
• b) Create a plan for targeted messages for each knowledge
user group
• c) Start the process of identifying the Quality Indicators
from the guidelines
Overview Dissemination Activities
 Completed
1. Publications (open access J Rheum / CRA website)
2. Presentations (Local, regional, national international)
3. Additional tools for download (CRA website)
4. CRA guideline self-evaluation survey followed by CRAJ
question and answer series (Summer 2013)
 In progress
1. MDbriefcase eRecommendation program (CME accredited)
2. EMR integration
 In future
Multi-disciplinary RA guideline dissemination workshop
September 2013
Presentation Outline
• Dissemination activities
• Moving towards the Quality Indicators
Development of Canadian Quality of
Care Indicators for RA
Developing QIs
Clinical Practice Guidelines
Define the optimal standard of care
Quality Indicators
Define the minimally acceptable
standard of care
Definitions
Quality Measure
• Measures the performance
• Has detailed specifications (numerator/denominator)
Number of eligible patients receiving a process of care (×100)
Number of patients eligible for a process of care
Example: “the percentage of patients age 18 and older
who were prescribed, dispensed, or administered at
least one ambulatory prescription for a DMARD during
the 12-month reporting period”
Another Example: TB screening
Numerator
• Patients with a TB screening within six months prior to
receiving a first course of a biologic DMARD
Denominator
• Patients  18 years with RA and receiving a first course
of a biologic DMARD
Denominator Exclusions
• Medical reason for not screening for TB
– Patient positive for TB and documentation of past
treatment
– Patient who has recently completed a course of
anti-TB therapy
Evolution of Quality of RA Care
RHEUMATOID ARTHRITIS GUIDELINES
2000
2002
2004
2006
2008
2010
2012
Evolution of Quality of RA Care
RHEUMATOID ARTHRITIS GUIDELINES
2000
2002
2004
2006
2008
2010
2012
2010
2012
RHEUMATOID ARTHRITIS QUALITY MEASUREMENT & IMPROVEMENT
2006
2008
From RA Guidelines to QIs
ACR 2012 RA QIs
1. Assessment of Disease
Activity
2. Assessment of Functional
Status
3. TB testing
4. Treatment with DMARDs
5. Administration of influenza
vaccine
6. Administration of
pneumococcal vaccine
7. CBC, Cr and LFT check
Canadian QIs- In progress
To develop evidence- and
consensus-based quality
indicators for the care of
Canadian adults living with RA
using current CRA guidelines
Acknowledgment
RA Guidelines Working Group
Dr. Pooneh Akhavan
Dr. Vivian Bykerk
Dr. Claire Bombardier
Mrs. Anne Dooley
Dr. Paul Haraoui
Dr. Glen Hazlewood
Dr. Majed Khraish
Dr. Sharon LeClercq
Mr. Jean Légaré
Dr. Diane Mosher
Dr. James Pencharz
Dr. Janet Pope
Ms. Orit Schieir
Dr. John Thomson
Dr. Carter Thorne
Dr. Michel Zummer
CRA On-line Survey
Dr. Sanjay Dixit
For any queries/ comments about CRA
recommendations for RA, please contact
raguidelines@rheum.ca