Since 2006, the Centers for Medicaid & Medicare Services (CMS) has increasingly driven clinicians to focus on and improve quality. Quality measures help clinicians measure how well they treat their patients. By tracking their performance, clinicians can identify opportunities to improve patient care while meeting federal reporting requirements.
Breaking Down Quality Measures
The CMS has created many different types of quality measures, including CQMs, eCQMs, Medicare Part B Claims measures and newly proposed dQMs. Although the type of measure varies, the development fundamentals stay the same.
Quality measures are created using the latest research with important treatment implications; many are based on clinical practice guidelines. Evidence-based guidelines are developed to reduce inappropriate care, minimize geographic variation in practice patterns and enable effective use of healthcare resources. Adherence to practice guidelines is voluntary and cannot guarantee any specific outcome, but they are intended to provide guidance for patterns of practice.
Because these guidelines are aimed at producing quality outcomes, they are a natural basis for outcome measures. A workgroup of ACR experts and patient voices analyzes guidelines and pinpoints specific measurable processes and outcomes. Concepts are then converted into numerators and denominators to track adherence to guidelines or directly measure meaningful outcomes. These measures are then tested and refined based on testing results. Once finalized, the measure can be implemented to give clinicians feedback on their care.
In addition to CMS-stewarded measures and those freely available as part of the CMS Quality Payment Program (QPP), measures can be developed by Qualified Clinical Data Registries (QCDR), such as the ACR RISE Registry. CMS-approved QCDR measures are an additional set of quality measures available only for reporting through the respective QCDR.
The ACR’s RISE Registry has created rheumatology-specific QCDR measures to give rheumatology clinicians a targeted understanding of the value of their patient care. These measures are only available through RISE.
Overall, quality measures help give individual datapoints collected during clinical care more meaning and context by tracking over time. They illustrate that the choices clinicians make now can have long-lasting impacts on patients and society. It is critical for clinicians to take charge of their performance, and quality measures can light the way.
RISE Registry QCDR Measures Overview
Name: ACR10: Hepatitis B Safety Screening
Description: If a patient is newly initiating biologic OR new synthetic DMARD therapy (e.g. methotrexate, leflunomide, etc.), then the medical record should indicate appropriate screening for hepatitis B in the preceding 12-month period.
Rationale: The primary safety concern with the use of biologic drugs is increased risk of life-threatening infections, including worsening or reactivation of viral hepatitis that can lead to liver damage or even failure. The FDA has received reports of preventable adverse events, including fulminant hepatic failure from hepatitis B in patients taking biologics like rituximab without appropriate preventive precautions. The 2012 American College of Rheumatology Guidelines for rheumatoid arthritis (RA) recommended not using biologics in RA patients with untreated chronic Hepatitis B; the 2015 update of these guidelines provides detailed guidance on treatment in the setting of hepatitis B infection.
Name: ACR12: Disease Activity Measurement for Patients with PsA
Description: If a patient has psoriatic arthritis, then disease activity using a standardized measurement tool should be assessed at greater than or equal to 50% of encounters for PsA.
Rationale: Regular assessment of functional limitations and disease activity are foundational concepts for treatment planning and clinical decision making for patients with psoriatic arthritis. Further, while the underlying physiological pathways are distinct between rheumatoid arthritis and psoriatic arthritis, the guidelines for both diseases explicitly recommend a treat-to-target approach, requiring clinicians to conduct disease activity and functional status assessment regularly and using standardized, validated tools. (PsA Guidelines: https://www.rheumatology.org/Portals/0/Files/PsA-Guideline-2018.pdf)
Name: ACR14: Gout: Serum Urate Target
Description: The percentage of patients aged 18 and older with at least one clinician encounter (including telehealth) during the measurement period and a diagnosis of gout treated with urate-lowering therapy (ULT) for at least 12 months, whose most recent serum urate result is less than 6.0 mg/dL.
Rationale: Patients with hyperuricemia are subject to recurrent gout flares and formation of tophi, which can lead to joint and other tissue damage. Urate lowering therapy reduces the frequency of acute gouty attacks and reduces the rate of growth of tophi and decreases the size of tophi. A recent randomized clinical trial comparing nurse-led treat to serum urate target showed that reducing the serum urate level resulted in reduced flare frequency, reductions in tophi, better quality of life, and lower cost per quality-adjusted life-year (QALY) gained, compared to usual care by physicians.1
For patients with indications for serum urate lowering therapy, after starting therapy, the goal of treatment is serum urate less than 6.0 mg/dL. Lower serum urate levels are associated with fewer acute gout attacks and decreased formation (and improvement) of tophi. Patients on ULT who do not achieve target serum urate less than 6.0 mg/dL are 75% more likely to flare than patients who reach target.
The ACR guideline on gout recommends that if a patient with gout has been treated with urate lowering therapy for at least 12 months, then the serum urate should be checked at least once yearly and the serum urate level target should, at a minimum, be 6.0 mg/dL.
Name: ACR15: Safe Hydroxychloroquine Dosing
Description: If a patient is using hydroxychloroquine, then the average daily dose should be less than or equal to 5 mg/kg.
Rationale: The risk of retinal toxicity and subsequent visual loss from hydroxychloroquine is dependent on daily dose and duration of use. Overall, 7.5% of individuals taking hydroxychloroquine for more than five years may have signs of retinal damage detected on specialized tests. To reduce the risk of retinal toxicity, the Royal College of Ophthalmologists and 2016 American Academy of Ophthalmology (AAO) updated guidelines recommend a maximum dosing of equal to or less than 5mg/kg/day of ideal body weight (IBW). As there are not guidelines specifically directed at optimal hydroxychloroquine dosing in rheumatic disease patients, the ACR chose to define the target dosing based on AAO’s recommendations.
Name: ACR16: Rheumatoid Arthritis Patients with Low Disease Activity or Remission
Description: The risk-adjusted proportion of individuals with RA who have low disease activity or are in remission based on the last recorded disease activity score as assessed using an ACR-preferred tool in the measurement year.
Rationale: RA has a significant impact on quality of life and function and it increases mortality.2-4 There is universal agreement, as evidenced by multiple clinical guidelines supporting the treat to (low disease activity/remission) target, that disease control is critical to reducing the risk of disability and disease-related complications.5,6 Further, newer evidence suggests clinicians should consider tapering DMARD therapy after prolonged remission, to reduce medication-associated risks, increasing the need for a measure to help clinicians and patients monitor RA disease activity over time.7 The required disease activity instruments capture both patient and physician assessment of disease activity and reflect validated, reliable and responsive metrics for capturing disease activity. This measure fills an important measure gap for patients with RA and their clinicians to track and monitor disease activity. Because it is not risk adjusted, performance comparisons across clinicians should consider the patient case mix to better enable performance comparisons.
Improved Quality Improvement
Data generated by the above QCDR measures may be more meaningful for rheumatologists than the more general quality measures currently used for CMS quality programs. Clinicians are encouraged to join the RISE registry to access and track their performance on these rheumatology-specific measures.
