In the past 20 years, measuring healthcare quality has received increasing attention. For rheumatology, the ACR and other organizations have developed quality indicators and quality standards for monitoring and improving quality of care for patients with rheumatoid arthritis (RA). In Canada, the Arthritis Alliance of Canada has developed an approach to models of care for inflammatory arthritis and a framework for model-of-care evaluation. As part of this framework, six system-level performance measures for inflammatory arthritis care capturing early access to care and treatment for inflammatory arthritis patients were developed.
To assess the adherence to these performance measures, Claire H. Barber, MD, PhD, FRCPC, University of Calgary, Calgary, Alberta, Canada, and colleagues accessed information about early RA patients from a pan-Canadian study, the Canadian Early Arthritis Cohort (CATCH). CATCH is a multicenter cohort representative of early RA patients treated in rheumatology practices across Canada. However, data for all six performance measures were not available in the cohort. Therefore, researchers focused on data for the following measurese: the percentage of RA patients seen in yearly follow up, the number of gaps of more than 12 or more than 14 months between visits, the percentage of RA patients treated with a disease-modifying anti-rheumatic drug (DMARD) and days from diagnosis to the initiation of a DMARD. This study represents the most comprehensive examination of the recently published system-level performance measures for inflammatory arthritis in Canada.
The study included 1,763 early RA patients from CATCH, enrolled between January 2007 and May 2016. Measures are reported between 2007 and 2015 except for time-to-DMARD therapy, which is reported until 2014. The results of the analysis were published in June 2018 Arthritis Care & Research.
The Results
“In this study, we observed high rates of adherence to the three performance measures that could be captured in CATCH, including high rates of yearly follow up, DMARD use and a high percentage of patients treated with a DMARD within the benchmark of two weeks,” write the authors in their discussion. “[Although] overall rates of adherence to the measures were high, a small decline in yearly rates of rheumatologist visits and DMARD use was observed with increasing length of cohort follow-up. Conversely, a trend toward an increased rate of patients treated with DMARDs within the 14-day benchmark was observed with increasing calendar year.”
Over the study’s eight years, the proportion of patients seen in annual follow-up declined from 100% to 91%. During follow-up, 42% of patients had no gaps in care when percentages were calculated using a 12-month window. Additionally, 64% of patients had no gaps when percentages were calculated using a 14-month window.
Due to appointment scheduling and insurer requirements, a 14-month window seems optimal for measuring follow-up, the researchers write. However, they also note that more research is needed to determine if adherence to a 12- vs. a 14-month window of follow-up affects patient outcomes.
In the study, the percentage of DMARD-treated early RA patients was and remained high (95–87%). Additionally, the percentage of patients receiving DMARDs within 14 days of diagnosis was 75%. Median time-to-DMARD therapy was one day, indicating DMARDs were initiated at diagnosis. Prior research links delays in starting DMARD therapy to worse outcomes for patients. “Most significant delays to therapy occur due to delays in access to rheumatology [care] and time-to-DMARD start [after] a patient is seen by a rheumatologist is often negligible, a finding confirmed by our study,” note the authors.
The authors conclude by noting that testing performance measures is crucial prior to implementation. “Additionally, future studies examining patient and provider factors that impact measure performance will be important to conduct, to better understand how to improve any observed gaps in care. [Although] the rates of adherence in this cohort were high, lower adherence will perhaps be observed with other data sources, but the current results may be used in benchmarking.”
Barber CEH, Schieir O, Lacaille D, et al. High adherence to system-level performance measures for rheumatoid arthritis in a national early arthritis cohort over eight years. Arthritis Care Res (Hoboken). 2018 Jun;70(6):842–850.