Quality Measurement Improves Rheumatology Outcomes

The investigators found that last-minute scheduling was the greatest contributor to scheduling errors, and it was one of the errors involved in the precursor event. That patient apparently received an incorrect medication, for which there was a standing order with no expiration date. “Fortunately, the patient did not experience any significant or lasting harm,” said Dr. Lu.

She stated that their goal at the medical center is to achieve a 0% error rate on all intravenous infusions by May 2012. They are attempting to reach this goal by analyzing system failures and improving work processes, including standardizing order sets and implementing provider checklists for infusions.

The hospital now has a standard 90-day expiration date for signed and held orders and is improving its computer order-entry system. Although they need to computerize steps of the protocol to improve reliability of the process, Dr. Lu told The Rheumatologist that they also are involving people to make the system adaptable. They plan to involve parents more by giving them information to help keep track of their children’s infusions, she said.

Guideline Adherence

Dr. Kohler

Since the ACR issued its “2010 Recommendations for the Prevention and Treatment of Glucocorticoid-Induced Osteoporosis,” researchers have shown that adherence to one of these recommendations is poor, said Minna J. Kohler, MD, who presented the results of a study to improve care providers’ adherence. The intervention focused on the ACR’s recommendation for calcium and vitamin D supplementation for patients receiving “any dose or duration” of glucocorticoid therapy.

Dr. Kohler conducted the research while at Veterans Affairs Connecticut Healthcare System and Yale University School of Medicine in New Haven. Dr. Kohler is now with Massachusetts General Hospital in Boston as director of the rheumatology unit’s Musculoskeletal Ultrasound Program.

The researchers designed a computerized prescription order set that automatically prescribes calcium and vitamin D each time a provider orders oral glucocorticoid treatment lasting two weeks or longer. After the intervention, the percentage of coprescriptions for calcium and vitamin D increased significantly (P<.0001 each). However, the postintervention adherence rate was only about 50%. “We had expected more of an increase,” said Dr. Kohler.

They found that a major barrier to better adherence was the lack of awareness by primary-care physicians, who were the most frequent prescribers of glucocorticoid medications in the study. “Some providers said they were unaware of any evidence supporting the ACR recommendation [for calcium and vitamin D supplementation] for any duration of glucocorticoid use,” she said.