Quality Patient Care in Rheumatology a Challenge to Define, Measure

What does it mean to provide good quality of care to our rheumatology patients? How do we measure quality and demonstrate its presence to regulatory agencies, third-party payers, and our patients? With the rapid pace of change and increasing cost of healthcare delivery, there is a renewed interest in improving the quality of care, though these questions are not easy to answer. The time to think about how we as rheumatologists deliver high-quality care is now. The ACR has published a White Paper that describes the College’s perspective on the approach to quality measurement.¹ Efforts are currently underway by the ACR to develop robust quality measures in rheumatoid arthritis (RA), gout, and glucocorticoid-induced osteoporosis. Yet, in order to demonstrate that we are improving health outcomes and creating value for our patients, we will need to do more.

Defining Quality Healthcare

The Institute of Medicine defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”² Michael Porter, PhD, of the Harvard Business School in Boston, suggests a different approach that defines value as outcomes achieved per dollar spent.³ In this context, quality takes into account outcomes and efficiency, so that all the stakeholders in the healthcare system are aligned with the same goal in mind: providing care that is of highest value to the patient. This premise may also require a change in the reimbursement system, from a traditional fee-for-service framework to a bundled payment model.

Often, “quality metrics” have little to do with outcomes and more to do with process measures—which may (or may not) lead to an appropriate outcome. It is for this reason and others that we have difficult time defining quality measures. Is it sufficient to simply order a test—such as a bone density—to meet a quality metric? Should outcomes always be imputed as a necessity for any quality metric to be considered good? The real issue is the cost of care, as we spend 17% of GDP on healthcare costs, and yet our quality outcomes are questionable. A 2007 report from the Commonwealth Fund observed that “compared with five other nations—Australia, Canada, Germany, New Zealand, the United Kingdom—the U.S. healthcare system ranks last or next to last on five dimensions of a high-performance health system: quality, access, efficiency, equity, and healthy lives.”⁴ While there have been improvements in the approach to quality of care since then, these observations suggest a steep learning curve ahead.