abstract 1027| · pdf file1 rheumatoid arthritis practice performance (rapp) project...

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R H E U M A T O I D A R T H R I T I S P R A C T I C E P E R F O R M A N C E ( R A P P ) P R O J E C T

David Sikes1, James Bower2, Drew Johnson2, Timothy Harrington2, Rafia Khalil3 Edmund LaCour4, Michael Narendorp5, Hillary Norton6, Kathleen Thomas7

from the Rheumatoid Arthri/s Prac/ce Performance (RAPP) Project 1Florida Medical Clinic PA, Zephyrhills, FL 2Joiner Associates LLC, Madison, WI

3Rafia Khalil Arthri/s & Rheumatology Center, Port Huron, MI 4Dothan Medical Associates PC, Dothan, AL 5Harlem Rheumatology LLC, New York, NY 6Santa Fe Rheumatology,

Santa Fe, NM 7Community Rheumatology, Noblesville, IN

Abstract #1027 | Session: Quality Measures and Quality of Care

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Crescendo Bioscience provided consulTng fees to Joiner Associates and support for RAPP Project advisory board meeTngs.

Joiner Associates LLC received consulTng fees from Crescendo Bioscience for designing and coordinaTng the Rheumatoid ArthriTs PracTce Performance (RAPP) Project – without any influence from the company.

D Sikes, R Khalil, E LaCour, M Naarendorp, H Norton, K Thomas, Crescendo Bioscience5 | K Thomas, Crescendo Bioscience8

J Bower, T Harrington, Crescendo Bioscience5

D Johnson, Crescendo Bioscience3 (prior to 7/1/15)

3Employment (full or part /me) | 5Consul/ng fees or other remunera/on (payment) 8Speaker’s bureau

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The RAPP Project is a clinician-‐led quality improvement iniTaTve designed to improve care using clinical populaTon management.

How we define CLINICAL POPULATION MANAGEMENT

It’s an approach to managing chronic diseases that includes: §  Enrolling all paTents in a populaTon registry. § Providing standardized on-‐Tme disease acTvity assessments. §  Focusing physician work on paTents with high and moderate disease acTvity and other problems.

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RAPP CLINICIANS’ COMMITMENT: At least every 3 months for paTents with moderate and high disease acTvity and every 6 months for paTents with controlled and low disease acTvity.

TREAT-‐TO-‐TARGET TASK FORCE: “… as frequently as monthly for paTents with high/moderate disease acTvity or less frequently (such as every 3-‐6 months) for paTents with sustained low disease acTvity or remission.”

Smolen JS, et al. Ann Rheum Dis 2010;69:631-‐37

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Determine on-‐Tme assessment rates.

Understand reasons for any observed care gaps.

Implement pracTce changes to provide on-‐Tme assessments.

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RAPP Project PracTces Included in Study

Total RAPP PracTces 168

RA PopulaTon Registry Implemented 112

Full RA PopulaTon Enrolled in Registry 86

RepresentaTve PracTces Analyzed 26

The variable rates of adop/ng clinical popula/on management are due to individual physicians preferences, prac/ce resources, and administra/ve barriers in different prac/ce environments.

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Data Flow Process

We developed a simple, doable clinical populaTon management process.

PopulaTon data and paTent work lists

PracTce team

PopulaTon registry

PaTent Data CollecTon Sheet

Physician/ pracTce team

PracTce staff or designated registry manager

STEP

TO

OLS

WHO

1 Document paTent data

2 Enter data in populaTon registry

3 Analyze

populaTon data

4 Improve care and workflows

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Patient Data Collection Sheet RAPP PROJECT: RA DISEASE ACTIVITY MEASURES

Date _____/_____/_____ Physician: Dr. Jamie E. Jones

PATIENT INFORMATION (Fill out or affix label in upper right)

Name _________________________________________________ DOB _____/_____/_____ ! M ! F

YEAR OF RA ONSET ___________ (Optional)

DATA ENTRY OPTIONS

1) You may submit this sheet to Crescendo Bioscience for data entry if using VectraView as your analytic registry: a) Send via secure fax to 877-743-8640; or b) Place in Vectra DA box with specimens; or c) Staple to patient’s Vectra DA order. 2) Your practice may enter the data directly into your chosen analytic registry. !

Start Stop Dose

! ! ! Azathioprine

! ! ! Sulfasalazine

! ! ! Hydroxychloroquine

! ! ! Methotrexate

! ! ! Leflunomide

! ! ! Prednisone

! ! !

! ! ! Infliximab (Remicade)

! ! ! Etanercept (Enbrel)

! ! ! Adalimumab (Humira)

! ! ! Certolizumab (Cimzia)

! ! ! Golimumab (Simponi)

! ! ! Tofacitinib (Xeljanz)

! ! ! Tocilizumab (Actemra)

! ! ! Abatacept (Orencia)

! ! ! Rituximab (Rituxan)

! ! !

! ! !

Biol

ogic

s

MEDICATIONS (Optional)Check a box for each medication that applies.

Recording dose is not required.

DMAR

Ds

Continue

REV10/14

* Poor prognosis = one or more of these: functional loss, rheumatoid nodules, erosions, positive RF and/or anti-CCP, extra-articular disease (i.e., Sjogren’s) !

Value Assessment (Range)MD Global (0-10)SJC (28/28) (0-28)TJC (28/28) (0-28)Prognosis* (Good or Poor)

Other:Morning Stiffness (15-min increments)

Patient Pain Index (0-10)Patient Global (0-10) HAQ (0-10) MD-HAQ (0-10)RAPID3 (0-30)Other:CRP (1-10)ESR (0-100)X-ray (Erosions: Y/N)Ultrasound (Erosions: Y/N)USES (0-24)Other:CDAI (0-76)DAS28-CRP (0-9.4)DAS28-ESR (0-9.4)GAS (0-62)SDAI (0-86)Other:

Com

posi

tePa

tient

MEASURES

Record the value of each assessment used systematically across your entire RA patient population.

Phys

icia

nLa

bs /

Imag

ing

7

22

Ron Lopez

2003

54

xx

1 23 45 x

Disease AcTvity Measures Used

Patient Data Collection Sheet RAPP PROJECT: RA DISEASE ACTIVITY MEASURES

Date _____/_____/_____ Physician: Dr. Jamie E. Jones

PATIENT INFORMATION (Fill out or affix label in upper right)

Name _________________________________________________ DOB _____/_____/_____ ! M ! F

YEAR OF RA ONSET ___________ (Optional)

DATA ENTRY OPTIONS

1) You may submit this sheet to Crescendo Bioscience for data entry if using VectraView as your analytic registry: a) Send via secure fax to 877-743-8640; or b) Place in Vectra DA box with specimens; or c) Staple to patient’s Vectra DA order. 2) Your practice may enter the data directly into your chosen analytic registry. !

Start Stop Dose

! ! ! Azathioprine

! ! ! Sulfasalazine

! ! ! Hydroxychloroquine

! ! ! Methotrexate

! ! ! Leflunomide

! ! ! Prednisone

! ! !

! ! ! Infliximab (Remicade)

! ! ! Etanercept (Enbrel)

! ! ! Adalimumab (Humira)

! ! ! Certolizumab (Cimzia)

! ! ! Golimumab (Simponi)

! ! ! Tofacitinib (Xeljanz)

! ! ! Tocilizumab (Actemra)

! ! ! Abatacept (Orencia)

! ! ! Rituximab (Rituxan)

! ! !

! ! !

Bio

logi

cs

MEDICATIONS (Optional)Check a box for each medication that applies.

Recording dose is not required.

DM

AR

Ds

Continue

REV10/14

* Poor prognosis = one or more of these: functional loss, rheumatoid nodules, erosions, positive RF and/or anti-CCP, extra-articular disease (i.e., Sjogren’s) !

Value Assessment (Range)MD Global (0-10)SJC (28/28) (0-28)TJC (28/28) (0-28)Prognosis* (Good or Poor)

Other:Morning Stiffness (15-min increments)

Patient Pain Index (0-10)Patient Global (0-10) HAQ (0-10) MD-HAQ (0-10)RAPID3 (0-30)Other:CRP (1-10)ESR (0-100)X-ray (Erosions: Y/N)Ultrasound (Erosions: Y/N)USES (0-24)Other:CDAI (0-76)DAS28-CRP (0-9.4)DAS28-ESR (0-9.4)GAS (0-62)SDAI (0-86)Other:

Com

posi

teP

atie

nt

MEASURES

Record the value of each assessment used systematically across your entire RA patient population.

Phy

sici

anLa

bs /

Imag

ing

10 18 14

This is an illustra/on of the form we use to collect pa/ent disease ac/vity data. It enables quick documenta/on of physician, pa/ent, laboratory, and composite measures. Current medica/ons can also be recorded, but this is op/onal.

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AnalyTc Registry

Patient DOB Year of Onset

# of Assmnts

MB Test Date CDAI Date RAPID3 Date MD

Global Date

Skip Stone 09/03/30 2001 7 35 03/11/15 5.5 04/18/14 6 04/18/14 2 04/18/14

Bonnie Anne Klyde 05/07/51 1969 22 16 05/21/14 7.5 08/13/14 15.5 02/12/15 1 08/13/14

Virginia Beech 09/04/30 1994 14 56 01/27/15 11 12/02/14 9.5 12/02/14 4 12/02/14

Jack Pott 12/20/41 1970 24 37 12/02/14 8 12/16/14 4.8 12/16/14 3 12/16/14

Dusty Carr 10/14/57 1970 18 47 12/12/14 14 01/16/15 7.3 01/16/15 5 01/16/15

Edna May 01/27/50 1970 26 44 01/22/15 7 01/22/15 1 01/22/15 2.5 01/22/15

Polly Ester 12/21/25 1993 15 25 10/07/14 4 01/23/15 0 09/04/13 7 01/23/15

Evan Keel 04/17/40 1970 24 36 01/16/15 11 01/27/15 13.3 01/27/15 3 01/27/15

Manny Kinn 12/13/25 2009 21 40 02/04/15 11 02/04/15 15.7 02/04/15 2.5 02/04/15

Anne Teak 09/07/30 1965 15 58 09/22/14 8 02/09/15 16.7 02/09/15 4 02/09/15

Will Power 09/07/30 1965 15 58 09/22/14 8 02/09/15 16.7 02/09/15 4 02/09/15

Crystal Claire Waters 06/22/45 1970 6 60 01/19/15 17 02/24/15 1.5 02/24/15 8 02/24/15

Marsha Mellow 12/19/25 1994 22 31 02/10/15 3 02/24/15 6.5 02/24/15 1 02/24/15

Corey Ander 07/13/44 1970 27 54 07/09/14 15 03/04/15 11.2 03/04/15 4 03/04/15

B.A. Ware 03/05/36 1965 20 36 01/06/15 13 03/23/15 14.2 03/23/15 2 03/23/15

Barb E. Dahl 03/12/41 1969 26 64 03/30/15 15 03/30/15 18.5 03/30/15 2.5 03/30/15

Adam Zaple 02/12/45 1962 41 49 12/04/14 23 04/01/15 13.3 04/01/15 5 04/01/15

Charity Case 10/11/36 1970 27 38 01/23/15 7 04/28/15 12 04/28/15 2 04/28/15

This chart illustrates what the pa/ent data looks like once entered into the spreadsheet format of a popula/on registry.

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Disease AcTvity Measures Reported

Measure Physician’s ReporTng

Physician Global (0-‐10) 39

CDAI 15

RAPID3 15

MulT-‐biomarker test 86

Many more physicians have collected a mul/-‐biomarker test than other measures it’s been captured in the registry for a longer /me. We as a group are agnos/c to which test is used -‐ physicians are individually able to choose.

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MulT-‐biomarker TesTng Data

Study Registries 26

PaTents enrolled Total 19,173 Median by physician 637 Range 84-‐2120 PaTents assessed Total 15,611 Median by physician 562 Range 25-‐1560

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Disease AcTvity DistribuTons MulT-‐biomarker TesTng Data

Disease AcTvity Level % of Assessed

Controlled/low disease acTvity 21

Moderate disease acTvity 38

High disease acTvity 40

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On-‐Tme Assessment Rates for MulT-‐biomarker TesTng Data

Disease AcTvity Level Median (range)

Controlled/low disease acTvity 43 (14-‐100) (% assessed within 6 months)

Moderate disease acTvity 29 (12-‐100) (% assessed within 3 months)

High disease acTvity 27 (10-‐100) (% assessed within 3 months) The percentages of pa/ents assessed on-‐/me (as defined by RAPP physicians’ inten/ons) were surprisingly low.

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…a bonleneck caused by too few visit slots to provide on-‐Tme physician assessments for all paTents.

Rheumatoid Arthri/s Prac/ce Performance Project spots problems in RA management, The Rheumatologist, June 2015

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ConducTng assessment visits prior to physician management visits.

GeneraTng registry work lists of paTents in need of assessment.

Focusing physician work on sicker paTents and new consults by building team care.

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Disease acTvity assessments are not provided as recommended.

Treatment cannot be opTmized without on-‐Tme assessments.

Clinical populaTon management is required for on-‐Tme assessments.

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JOIN US AT OUR POSTER PRESENTATIONS 8:30 AM -‐ 4:00 PM Tuesday | Poster Presenters 9:00 -‐ 11:00 AM)

#2487: Clinical pracTces parTcipaTng in quality improvement project make progress in implemenTng populaTon management.

Session: Health Services Research Poster III: Pa/ent Reported Outcomes, Pa/ent Educa/on and Preferences

#2317: Different rheumatoid arthriTs disease acTvity measures ooen

provide discordant results in clinical pracTce populaTons. Session: Quality Measures and Quality of Care

abstract 1027| · pdf file1 rheumatoid arthritis practice performance (rapp) project...

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