Quality Patient Care in Rheumatology a Challenge to Define, Measure

The Gorilla in the Room: Cost of Care

With the advent of so many options to treat RA and the efficacy of biologic DMARDs, the issue of controlling costs becomes critical. Adalimumab is the highest-grossing drug in the world, with sales approaching $9 billion.¹² With emerging data suggesting that some patients may stay in remission even when using lower doses of biologic drugs, there may be opportunities to achieve good clinical outcomes while still lowering overall cost, thereby leading to high-value care for our patients.¹³ However, defining “outcomes” in a chronic disease like RA remains challenging. Should it be the absence of radiographic progression, or is it clinical remission as defined by a DAS-28, CDAI, or RAPID3 scores, or is it simply global functional status? Radiographic outcomes are not routinely calculated in clinical practice and thus are not readily available as a way to measure RA outcomes. Standardized assessments of disease activity are not performed on every patient at every visit in every rheumatology clinic—and even when they are done, the same instrument may not be used, so comparing outcomes may be inconsistent across patients or practices. Lastly, although patient-reported outcomes are gaining popularity and arguably may represent the most important perspective on RA, we need to understand how to best incorporate this data into our busy clinical practices. Do we feel confident that we, as rheumatologists, will find the time to regularly perform these measures of disease activity and utilize the data effectively?

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Table 1: ACR “Top 5” Choosing Wisely List¹⁴

Making our Efforts Meaningful

What about testing overuse? To think critically about efficiency of care, the ACR has partnered with the American Board of Internal Medicine (ABIM) in the “Choosing Wisely” campaign to develop a “Top 5” list of commonly ordered tests, treatments, or services used in rheumatology, but whose utility is questioned. They include: antinuclear antibody and Lyme antibody testing, the role for magnetic resonance imaging and bone densitometry, and the use of biologic DMARDs (see Table 1). How this list will be used in the clinic and whether it may lead to reduced costs or improved outcomes remains to be seen.

With rising pressure to improve access to care and the fiscal need to see more patients as reimbursements decline and sequesters expand, it may become even more difficult to document and prove quality outcomes. The rising prevalence of electronic medical records encourages us to use them in a more “meaningful” way—but the additional responsibilities of the office staff and rheumatologists to enter data into the electronic medical records cannot be understated. Whether the adoption of the Medicare-supported Meaningful Use program actually improves the care our patients receive remains to be seen.¹⁴ Given the projections of demand for rheumatology care not being met by adequate supply, efficiency of care will become essential.¹⁵ Newer models of care, such as immediate access clinics, may allow for earlier diagnoses and initiation of therapy.¹⁶ We are at a critical point in the healthcare debate. We will need to define and measure our quality outcomes and value, or others may do it for us.