Measuring Quality of Measuring Quality of Care in People with Care in People with

ArthritisArthritis

Sarah Sampsel, MPHNational Committee for Quality

Assurance

AcademyHealth 2004©2004 by the National Committee for Quality Assurance

IntroductionIntroduction

• 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

ObjectivesObjectives

• Assess Desirable Attributes (HEDIS® )(selected)

– Feasibility: barriers to implementation

– Validity: age limits, exclusions, diagnoses

– ‘Actionability’: variation in performance across

plans and geographic regions

MethodsMethods

• Multi-disciplinary expert panel

• Volunteer testing by health plans

• Abstraction from administrative and

medical record data

Arthritis MeasuresArthritis 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 anti-

inflammatory drugs (NSAIDs) and receiving

gastrointestinal prophylaxis

• % of patients with rheumatoid arthritis receiving a

disease modifying anti-rheumatic drug (DMARD)

Principal FindingsPrincipal FindingsArthritis symptom assessment: documentation of

assessment of pain and functional statusDiagnosis Arthritis

Prevelance/1000 Pain

AssessmentFunctional

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 FindingsPrincipal Findings

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%

Osteoarthritis care: documentation of recommendations for weight loss and physical activity, acetaminophen use

*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

OA Prevalence/1000 members: Commercial: 1.2; Medicare + Choice: 78.1

Principal FindingsPrincipal Findings

Plan % Adult Members with NSAID Rx

% high risk patients with GI prophylaxis

A 11.9% 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%

Appropriate gastrointestinal prophylaxis for high risk patients utilizing prescription NSAIDs

C = Commercial; M+C = Medicare + Choice; Md = Medicaid

Principal FindingsPrincipal Findings

Plan RA Prevalence/1000

Commercial Medicaid Medicare

A C = 0.8

M+C = 5.4

67.6% N/A 71.4%

C C = 2.1

Md = 1.1

75.8% 76.5% N/A

Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis

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 FindingsSummary 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 FindingsSummary 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

ImplicationsImplications

• 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 WorkgroupMusculoskeletal 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

AcknowledgementsAcknowledgements• 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.