SAN FRANCISCO—Several converging currents put rheumatologists at risk of being caught in “the perfect storm,” believes Eric D. Newman, MD, director of rheumatology and vice chair of the Department of Medicine at the Geisinger Medical Center in Danville, Pa. Traditional healthcare faces increasing problems, therapies for rheumatoid arthritis (RA) are more effective but complex, and outcome expectations are increasing. But, as Dr. Newman and his fellow presenters at a session at the October 2008 ACR/ARHP Annual Scientific Meeting titled “2008 ACR Rheumatoid Arthritis Treatment Recommendations: How Can We Treat Our Patients Better?” proposed, the ACR’s proactive stance on treatment recommendations for RA can help rheumatologists chart a course for the future.
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In June 2008, the ACR unveiled the results of a prodigious work effort, “American College of Rheumatology 2008 Recommendations for the Use of Nonbiologic and Biologic Disease-Modifying Antirheumatic Drugs in Rheumatoid Arthritis.”1 The ACR session complemented these efforts by offering practical tools to implement the recommendations in a practice-based approach.
RA Care Changing Rapidly
Believing that evidence-based clinical practice recommendations are necessary for increasingly busy clinicians, the ACR had asked a task force panel to address five objectives regarding the use of nonbiologic and biologic disease-modifying antirheumatic drugs (DMARDs) in patients with RA:
- Their indications for use;
- Assessing clinical response;
- Screening for tuberculosis (TB; biologics only);
- Monitoring for side effects; and
- The roles of cost and patient preference in decision making (biologics only).
First, presenter Kenneth G. Saag, MD, professor of medicine and epidemiology at the University of Alabama in Birmingham, was a member of the core expert panel that conducted the extensive literature review and helped guide, along with the working group, the development of the recommendations. An expert task force panel used a modified Delphi process to reach consensus and enrich response categories for clinically detailed scenarios that would lead to RA treatment strategies.
The resulting recommendations comprise a dynamic document, Dr. Saag pointed out. “These recommendations provide a framework for future efforts. Although they’re extensive in scope, they are not comprehensive. They are meant to complement but not to eclipse individualized patient care,” he said. Some of the newer biologic agents were not included in the recommendations because the evidence to date was insufficient to elicit consensus by experts. Dr. Saag hopes that future updates of the recommendations will address the effectiveness of switching biological medications of the same mechanism (e.g., TNF blockers) and sequential biologic therapies, among other questions.
Measure, Measure, Measure
One of the key themes introduced by the recommendations is the necessity to regularly appraise patients’ symptoms and responses to treatment. For instance, because treatment algorithms are keyed to level of disease activity (i.e., low, moderate, and high), it’s imperative that patients’ disease activity be assessed. The developers of recommendations did not specify which instruments clinicians should use but did say that it ought to be done.
In the next section of the presentation, C. Kent Kwoh, MD, professor of medicine and epidemiology and chief of the Division of Rheumatology at the University of Pittsburgh, summarized the ACR’s collaboration with the National Committee for Quality Assurance and the Physician Consortium for Performance Improvement to translate the recommendations into quality and performance measures. Their efforts yielded five standards: assessment of an RA patient’s disease activity (low/moderate/high) at least once a year; assessment of the patient’s functional status; assessment and classification of disease prognosis at least once a year; TB screening for patients receiving biologic agents; and glucocorticoid management.
Dr. Kwoh said that the guiding principles for developing the standards were that they be clinically relevant, evidence based, scientifically valid, and, most important, feasible. He then demonstrated the computation of quality scores for each of the performance standards. For instance, to rate one’s performance on the standard of TB screening for RA patients receiving biologic agents, the practice would divide the number of patients who were screened for TB by the total number of patients receiving biologics. If the practice performed TB screening on 90 of the 120 patients receiving biologics, this would yield a score of 75%.
Taking the Challenge
Why is it important to implement quality measures? Asking the questions outlined in the performance standards, and tracking the answers, will boost the quality of care rheumatologists render to patients with RA, noted Dr. Newman. “My task is to take the elegant work summarized by my colleagues Dr. Saag and Dr. Kwoh and kind of bring it out to the clinic. There are skills you need to learn, steps you need to take, and processes to put into place in the clinic so that you can begin to collect these types of measures.”
Dr. Newman remarked that most rheumatologists, when asked if they deliver quality care, would answer in the affirmative. However, he also noted that many may not be able to quantify their answers with solid data. It’s important for rheumatologists to create a “culture of change,” he said, and outlined a five-step process to implement the recommendations’ quality measures into clinical practice. Dr. Newman used examples from the experience at Geisinger Medical Center as well as training workshops he conducts with colleague J. Timothy Harrington, MD, delivered with a humorous and energetic approach.
The first step, said Dr. Newman, is to commit: “The person in charge has to make it clear that this is a very, very important part of what we do for our patients.” Then it is time to get buy-in from others in the group. Typically, Dr. Newman said, 10% of a group will view change as fun and positive, 80% will be willing to listen, and 10% may resist. “Spend time with the key players,” he advised, “and focus on those who are receptive so that you can overcome inertia to change.” Next, form a team to address quality measures. The team should include all members of your microsystem, not just physicians and nurses. “The best way to meet with success is to create a team that circles around the patient. For that to happen, everybody has to be a player.” This may entail some adjustment from physicians, who tend to view the medical practice in a hierarchical way. Often, associated staff members have the best ideas, he said.
When you make a plan, depending on practice resources and experience with quality measures, you may first need to learn how to use tools such as questionnaires and also learn about redesign skills as well as the rapid change cycle. You may elect one of a variety of approaches: to start slowly by implementing just one quality measure, to “dive in” using a registry-based approach, or to “go for the gusto” with full-on electronic implementation. Dr. Newman emphasized that it’s recommended to start slowly and do trial runs to introduce quality measures one at a time. During this phase and throughout the change process, it’s important to praise staff for their efforts and give feedback.
Dr. Newman encouraged his audience to pick a path for measurement that makes sense for their individual practices and institutions, “and let ACR help you.” For instance, clinicians could consider using ACR’s Rheumatology Clinical Registry. (See “Rheumatology Clinical Registry Debuts This Month,” p. 1, for more information.)
Quality indicators are being used increasingly for quality-improvement efforts, for benchmarking, and, for pay-for-performance initiatives by the Centers for Medicare and Medicaid Services and other payers. To avoid the perfect storm, clinicians can take a proactive approach and implement quality measures into their practices. Wrapping up his talk, Dr. Newman left his audience with several inspirational quotes, including, “Change is difficult, but stagnation is fatal.”
Gretchen Henkel covered the 2008 ACR/ARHP Annual Scientific Meeting for The Rheumatologist.