A Multistakeholder Approach to Improving Quality in Rheumatoid Arthritis Proceedings from the Rheumatoid Arthritis Quality Expert Medical Panel By Jeffrey R. Curtis, MD; C. Kent Kwoh, MD; Albert J. Rizzoli, MD; John A. Welz, MPH

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e are in the midst of an ongoing transformation of the US healthcare system, the seeds of which were planted when the Institute of Medicine (IOM) formed its Committee on the Quality of Health Care in America in 1998. The IOM committee produced several influential reports over the years, including the 1999 report, To Err Is Human: Building a Safer Health System, which brought the issue of preventable medical errors to the public eye.1 In the landmark 2001 report, Crossing the Quality Chasm: A New Health System for the 21st Century, the IOM committee focused more broadly on how the healthcare system could be reinvented to inspire innovation and improve the delivery of care.2 The year 2010 saw the passage of the Patient Protection and Affordable Care Act (ACA), which sought to operationalize (and legislate) many of the changes recommended earlier. The ACA required the development of a National Quality Strategy to help foster an increased and sustained commitment to health and healthcare quality.3 The initial National Quality Strategy, published in March 2011, identified 3 overarching aims (including improvement in the quality of healthcare) and 6 longterm goals.4 A 2012 progress report identified 3 specific strategic opportunities to accelerate system-wide improvement; one of these included the development of a cohesive national strategy for data gathering, measurement, and reporting that encourages performance measurement and improvement efforts.5 The Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA) are 2 key stakeholders in spearheading the development and implementation of quality measures.6,7 According to CMS, quality measures are designed to help measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structures and/or systems that can provide high-quality healthcare.6 A number of other organizations are involved in developing quality measures, including the American Medical Association, the American College of Rheumatology (ACR), and other professional medical organizations; the Agency for Healthcare Research and Quality (AHRQ); and The Joint Commission.8-11 These

organizations typically submit measures for review by endorsement and approval organizations.12 Both CMS and the NCQA use standardized approaches to develop quality performance indicators.12 In response to increasing demand for metrics, the CMS has created the Measures Management System. The Measures Management System is designed to assist in the production of high-caliber quality measures that are appropriate for accountability. CMS-funded measure developers are expected to follow this core set of business processes and decision criteria. After prioritizing medical areas of interest, CMS-approved measure developers work with experts to research the evidence-based literature to identify candidate measures. Draft technical specifications for data collection and measure calculation are field tested for validity, reliability, and feasibility, and may undergo modifications as they evolve.13 Similar to CMS, the NCQA has mapped out a detailed process for the development of its Health Effectiveness Data and Information Set (HEDIS) quality measures. The process, which takes approximately 28 months from inception to adoption, includes the creation of technical subgroups to draft new measures; internal field testing and analysis; presentation to the Committee on Performance Measurement (CPM); and a public comment period during which interested parties, such as patient advocacy groups, professional organizations, and employer groups/ coalitions, can provide feedback on the technical specifications of draft measures.14 After a new HEDIS measure is launched, organizations have 1 year to collect, be audited on, and report about first-year measures––without having the results reported to the public. The CPM then reviews the results and decides whether to move the measure to public reporting.15 Using a consensus process to independently evaluate the feasibility, reliability, validity, and usability of voluntary measures submitted by various measure developers, quality measure endorsers also play an important role in establishing quality measures. The process is similar to the measure development process and includes multiple stakeholders to represent varied perspectives and knowledge.12 The National Quality Forum evaluates healthcare performance measures throughout the continuum of care.12,16

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Table 1 RA Physician Performance Measurement Set Measure developer

RA measure title

Description

Patients who were dispensed at least 1 DMARD prescription

Percentage of patients aged ≥18 years who were diagnosed with RA and were prescribed, dispensed, or administered at least 1 ambulatory prescription for a DMARD

NCQA

Periodic assessment of disease activity

Percentage of patients with RA aged ≥18 years who have an assessment and classification of disease activity at least once within 12 months

AMAPCPI/NCQA

Tuberculosis screening

Percentage of patients with RA aged ≥18 years who have documentation of a tuberculosis screening performed and results interpreted within 6 months prior to receiving first course of DMARD therapy

AMAPCPI/NCQA

Assessment and classification of disease prognosis

Percentage of patients with RA aged ≥18 years who have an assessment and classification of disease prognosis at least once within 12 months

AMAPCPI/NCQA

Functional status assessment

Percentage of patients with RA aged ≥18 years for whom a functional status assessment was performed at least once within 12 months

AMAPCPI/NCQA

Glucocorticoid management

Percentage of patients with RA aged ≥18 years who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >10 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months

AMAPCPI/NCQA

AMA-PCPI indicates American Medical Association-Physician Consortium for Performance Improvement; DMARD, diseasemodifying antirheumatic drug; NCQA, National Committee for Quality Assurance; RA, rheumatoid arthritis. Source: Centers for Medicare and Medicaid Services. 2014 Physician quality reporting system (PQRS) measures list. www.cms.gov/ apps/ama/license.asp?file=/PQRS/downloads/2014_PQRS_MeasuresList_ImplementationGuide_12132013.zip.

Quality measures that have been developed, tested, and endorsed are ready for implementation by providers, institutions, and payers, usually under the auspices of accrediting organizations such as The Joint Commission,17 the Utilization Review Accreditation Commission,18 or the NCQA.19 In an effort to improve transparency, public reporting of quality data has become commonplace, allowing patients, employers, and other purchasers of healthcare to make informed decisions based on performance.16

occupations, reduce their work hours, lose their jobs, and retire early.24 One study found that 51% of patients with at least 25 years of RA were no longer employed.25 Furthermore, RA is associated with earlier mortality; the average lifespan for patients with RA is estimated to be 3 to 12 years shorter relative to individuals without RA.26 Although RA places a substantial burden on patients, families, employers, and the healthcare system, little attention has been focused on improving the quality of care in this disease category. To address this issue, the RA Quality Expert Medical Panel was convened on August 23, 2013 in Chicago, Illinois, to bring together leaders in the rheumatology, payer, employer, and quality-improvement communities. Community-based rheumatologists represented the treating physician perspective, which focused on the individual patient. Payers and employers represented the population-based value perspective, of which economic considerations are key factors. Finally, individuals with a quality measure development background helped to shed light on how measures are envisioned, created, vetted, and implemented, which is a lengthy and complex process involving many different stakeholder organizations at different steps of the way. The panel was assembled to develop actionable strategic and tactical recommendations for all healthcare system stakeholders committed to delivering high-quality care for patients with RA. To that end, the sponsor

The Rheumatoid Arthritis Quality Expert Medical Panel Rheumatoid arthritis (RA), a systemic autoimmune inflammatory disease that mainly affects the small joints of the hands and feet, is responsible for premature disability and reduced quality of life worldwide.20 In the United States, more than 2.2 million individuals have RA; of these, an estimated 700,000 are not diagnosed or treated.21 Patients with RA use a disproportionate amount of healthcare services. In 2008, the annual total expenditures for patients with RA was more than 2.5 times that of individuals without RA.22 In 2012, there were 13,125 hospitalizations where RA was listed as the primary diagnosis; aggregate charges resulting from these inpatient stays totaled more than $535 million.23 In addition, RA affects workplace productivity; compared with people without RA, people with RA were more likely to change

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The Current State of Quality of RA Care Although 6 RA quality measures were developed and adopted, only 1—the DMARD therapy measure—has received widespread acceptance and use32; this same measure is used by payers and by providers alike. For payers, the NCQA HEDIS measure evaluates the percentage of health plan members whose RA was diagnosed and who were dispensed at least 1 ambulatory prescription for a DMARD.33 NCQA, HEDIS, and Payer Reporting Through their quality efforts, payers seek to promote the delivery of high-quality care among their member populations. For example, the NCQA publicly ranks payers according to their combined performance across a number of measurement domains (including HEDIS).34 In addition, the NCQA markets a measure-specific syndicated benchmarking and quality-trending tool called the Quality Compass.35 The national average of payer performance (HMO and PPO populations) on the DMARD therapy measure in 2012 is shown in Figure 1.36 The data show that commercial benefit design members are more compliant with the measure than their counterparts in the Medicare and Medicaid populations.36 This performance gap became particularly evident when the 25th percentile scores of all plans reporting to Quality Compass were analyzed. As

Payer performance on DMARD measure, %

History of RA Quality Measures In 2008, a group of 5 clinical performance measures, jointly developed by the ACR, the NCQA, and the Physician Consortium for Performance Improvement (PCPI), was published.27 These 5 measures were integrated in 2009 into the Physician Quality Reporting Initiative (PQRI)28— now known as the Physician Quality Reporting System (PQRS).29 Subsequently, a sixth measure based on disease-modifying antirheumatic drug (DMARD) use was developed by the NCQA, a leading accreditor of health plans and other payer organizations. This measure, often described as the DMARD therapy measure, was adopted as a HEDIS measure in 200530 and was also integrated into the PQRI measurement set.28 The 6 original RA quality measures, which remain in use essentially unchanged,31 are collectively described in Table 1.

National Average: Figure 1 Quality Compass Performance, DMARD Therapy Measurea (2012 Reporting Year) 100 90 80 70 60 50 40 30 20 10 0

87.2 74.2

Commercial plans

74.0

68.9

Medicare

Medicaid

CMS Star

DMARD therapy measure means the percentage of patients with RA aged 18 years and older who were prescribed, dispensed, or administered at least 1 ambulatory DMARD prescription. CMS indicates Centers for Medicare & Medicaid Services; DMARD, disease-modifying antirheumatic drug. Source: Data on file. Pfizer Inc, New York, NY.

a

Figure 2 Quality Compass Performance, 25th Percentile: DMARD Therapy Measure (2012 Reporting Year) Payer performance on DMARD measure, %

sought to identify reasons for variation in performance on RA quality measures, develop a strategic and tactical framework for performance improvement on the current RA quality measures, and share best practices for stakeholders to optimize RA quality measure scores. Going forward, the long-term goal of this engagement is to work toward a conceptual consensus framework for quality improvement in RA.

100 90 80 70 60 50 40 30 20 10 0

84.9

84.7 68.8

64.9

Commercial HMO/PMO

Commercial PPOs

Managed Medicaid

Medicare Advantage

DMARD indicates disease-modifying antirheumatic drug; HMO, Health Maintenance Organization; PPO, Preferred Provider Organization; POS, Point of Service. Source: Data on file. Pfizer Inc, New York, NY.

shown in Figure 2, only 64.9% and 68.8% of Medicaid and Medicare members, respectively, met the criteria for the DMARD therapy measure.36 There remains ample room for improvement in the DMARD therapy measure, especially for the Medicare and Medicaid populations. Conversely, a number of plans have compliance scores nearing 90% or more for their commercial members, as evidenced by the 90th percentile averages—93.5% with HMO/POS benefit designs and 92.8% for those with PPO coverage.36 According to several payers participating on the panel, these scores may represent the upper threshold that can be reasonably attained. During the panel discussion, it was pointed out that health plan scores on the HEDIS DMARD therapy mea-

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sure are derived from a denominator that includes all prescribers who treat patients with RA. Payers represented on the panel noted that many patients with RA do not receive their care from a rheumatologist. Although there are valid exceptions where DMARDs may be contraindicated, thereby affecting the numerator, there are data to suggest that primary care providers (PCPs) may be more reluctant than rheumatologists are to prescribe DMARD therapy.37 Furthermore, panel payers noted that PCPs treat patients with a broad range of medical conditions, and therefore may not be as familiar with the correct diagnosis codes for RA. Proper coding is critical; miscoding may result in patients being excluded from the numerator, leading to the underreporting of DMARD use, or inflation of the denominator with patients who do not have RA.

age, medical contraindication, and African American race. The authors concluded that perceived gaps in RA patient care identified by previous studies that used administrative data may have been somewhat overestimated, because the care was not provided for presumed valid reasons. It was noted that when the NCQA and the PQRS collect quality data, they do not include criteria (eg, reasons for not prescribing a DMARD) to exclude patients from the denominator.38 Although the data support the contention that valid exclusion criteria should be considered for the DMARD therapy measure, the fact remains that a substantial proportion of patients with RA do not receive the minimum standard of care for their illness.37,38

A Starting Point in RA Quality Measurement: The DMARD Therapy Measure Quality measurement begins with the development of clinically meaningful metrics that accurately characterize patient care. Unfortunately, there is no universally reported metric in RA that correlates well to outcomes (such as A1c for diabetes or blood pressure level for hypertension) that allows physicians to treat to a predefined, easily measurable goal or target.41 To this point, key stakeholders have been unable to reach consensus regarding optimal measures in RA. According to the panel, the DMARD therapy measure was developed as a starting point to permit rheumatologists and payers to measure quality of RA care. For that purpose, the measure has met its goal, and has been widely used by payers participating in the NCQA accreditation process and by rheumatologists participating in the PQRS. However, there was universal agreement among the panel members that the measure is inadequate to support clinically relevant measurement and quality improvement. In part, this is due to how the measure is defined. To be compliant, a patient needs only to receive 1 DMARD prescription during a 12month reporting period.31 This was viewed as the bare minimum standard of care by the panel participants, who noted that the measure did not in any way address medication adherence or continuity of care considerations. Another criticism of the measure is that it permits a broadly defined, lengthy list of DMARDs to be counted toward the numerator.42 Finally, rheumatologists on the panel indicated that the DMARD measure does not correlate with health status (while disease activity measure does correlate with health status); therefore, performance on this measure does not help payers determine whether their members’ RA has improved, worsened, or remained the same. Panel participants indicated that any RA quality-improvement initiatives using the DMARD therapy mea-

CMS, PQRS, and Physician Reporting Providers serving Medicare patients have the option to report RA quality care through the PQRS. Physicians can choose to report on any relevant PQRS measure. For rheumatologists, there are 6 measures that pertain specifically to the treatment of patients with RA.31 These measures were cited earlier and are listed in Table 1. Anecdotally, panel rheumatologists reported that compliance with the DMARD therapy measure is generally high among rheumatologists. To date, however, limited performance data have been published regarding performance on PQRS measures. Nevertheless, available data suggest that there is a quality gap in RA management, with substantial room for improvement by rheumatologists and especially PCPs.37,38 One study showed that during 12 months of follow-up, only 18.5% of patients who were seen by non-rheumatologists filled a prescription for a DMARD, compared with 53.3% of patients who were seen by rheumatologists.39 Another study found that DMARD use was significantly more frequent and persistent with continuous rheumatologist care. DMARDs were used by 10% of patients who were followed by family physicians, and by 84% of patients who were followed by rheumatologists.40 Despite the data indicating that non-rheumatologists’ performance lags far behind that of rheumatologists, it is worth noting that a substantial subset of rheumatologists did not meet the minimum standard of care in these studies.39 In another analysis of 630 physicians (primarily rheumatologists) who reported at least 1 PQRS measure for their patients in 2009, 76% of patients with RA received a DMARD prescription during the previous 12-month period. When a DMARD was not prescribed, physicians were asked to document the reason. The most frequent responses for not prescribing a DMARD included older

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Table 2 Required Components of RA Disease Activity Measures Recommended for Point-of-Care Clinical Usea Defined very Physician Patient Provider HAQ low disease joint count global VAS global VAS version Pain activity criteria Patient-driven composite tools PAS PAS-II RAPID3

HAQ HAQ-II MDHAQ

3 3 3

3 3 3

3 3 3

Patient and provider composite tool CDAI

3

3

3

N/A

3

Patient, provider, and laboratory composite tools DAS28 (ESR or CRP) SDAI

3 3

3 3

3

N/A

3 3

Measures are not shown in order of preferences. CDAI indicates clinical disease activity index; CRP, C-reactive protein; DAS28, Disease Activity Score with 28-joint counts; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire; MDHAQ, Multidimensional Health Assessment Questionnaire; N/A = not applicable; PAS, Patient Activity Scale; RA, rheumatoid arthritis; RAPID3, Routine Assessment of Patient Index Data with 3 measures; SDAI, Simplified Disease Activity Index; VAS, visual analog scale. Adapted with permission from Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012;64(5):640-647. Used with permission of the publisher, John Wiley & Sons Inc. All rights reserved.

a

sure are greatly hampered by their lack of meaningful clinical utility. As a result, very few such initiatives have been developed and implemented.

Alternate Measures of Quality of RA Care During the panel discussion, it was mentioned that several domains can be used to measure the quality of RA care; however, each has its advantages and disadvantages. For example, although measurement of the rheumatoid factor is used to help diagnose RA, it is not an appropriate measure of ongoing disease management. Likewise, an annual radiographic exam (x-ray) is useful for disease assessment, but it is retrospective, looking back at disease progression that has already taken place. Magnetic resonance imaging is a more sensitive technique than x-ray for detecting joint damage, but is substantially more expensive. Measurement of functional status using the Health Assessment Questionnaire and the Short Form-36 has been implemented in clinical trials and in some clinical practices. For most practices, however, these tools are time-consuming and can be difficult to adopt. Furthermore, there is the perception that the results are somewhat subjective, and they have limited applicability for real-time clinical care, thereby limiting their reliability as measurement tools. Nevertheless, patient-reported outcome measures are increasingly recognized as being important.43 The ACR has identified 6 RA disease activity measures for point-of-care clinical use as shown in Table 2. Three disease activity measures are patient-driven com-

posite tools that are designed to be completed entirely by the patient, and the other 3 disease activity measures comprise specific physician components, including tender and swollen joint count.44 The consensus of the panel was that routine measurement of RA disease activity using any of these instruments would be of great benefit in improving the quality of patient care and implementing a treat-to-target approach to managing patients with RA. Despite some of the limitations of core measures, the CMS integrated all 6 core measures developed by the ACR/NCQA/PCPI consensus group into the PQRS measurement set.31 Although the measures have remained essentially unchanged since their integration, the DMARD therapy measure is the only core measure that has received widespread adoption by the medical community. In one survey-based study, 95.8% of physicians reported on the DMARD measure, but only 34.0% and 29.0% of physicians (primarily rheumatologists) reported on measures of functional status and disease activity, respectively (Figure 3).38 These findings appear to corroborate data published in 2005, indicating that a low proportion of rheumatologists are using validated measures of disease activity as part of routine patient care, as shown in Table 3.45 Limited measurement of functional status and disease activity by rheumatologists, as well as by PCPs, supports several panelists’ contention that more physician education is required to ensure that patients with RA receive the best possible care.

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Determinants of Quality of RA Care The panel identified a number of critical factors that are currently affecting the care of patients with RA, including:

• Access to specialty care • Treatment variability • Patient adherence to treatment • Patient preferences • Patient identification and coding • Data integration and connectivity • Clinically meaningful metrics • Adequate incentives. According to the panel, each of these determinants contributes to the quality gap in RA, and therefore, measure developers should consider addressing 1 or more of these issues when initiating the process for new RA quality measures.

Physicians reporting measure for RA patients, %

Figure 3 P hysician Reporting on Selected PQRS RA Quality Measures 100

95.8

90 80 70 60 50 40

34.0

29.0

30

Access to Specialty Care Access to specialty care was cited as a leading determinant of quality of care in today’s RA treatment landscape. There is a shortage of rheumatologists in the United States, particularly in rural areas, and in some areas, patients must travel at least 200 miles to reach the closest rheumatologist.46 Patients without access to a rheumatologist may experience a delay in the initiation of DMARD therapy. The delay between symptom onset and initiation of DMARD treatment is a global issue, and one study found that fewer than 50% of patients with RA are treated with DMARDs within 6 months from symptom onset.47 Lack of access to a rheumatologist is believed to be a contributing factor to delayed DMARD treatment.48 General practitioners receive limited training in treating rheumatic disorders, and as discussed earlier, patients managed by nonrheumatology providers are far less likely to be compliant with DMARD therapy than those managed by rheumatology providers.39,40 Numerous studies have demonstrated that early DMARD treatment results in better outcomes,49,50 and the ACR supports the use of DMARD therapy in early RA.51 Therefore, the panel was supportive of quality initiatives that promoted early RA treatment with DMARD therapy.

20 10 0

DMARD therapy

Functional status

RA disease activity

DMARD indicates disease-modifying antirheumatic drug; PQRS, Physician Quality Reporting System; RA, rheumatoid arthritis. Source: Curtis JR, et al. Arthritis Care Res (Hoboken). 2013;65(2):235-243.

 se of Validated Measures of Disease Activity and Table 3 U Functional Status Physicians performing measure as part of routine Measure RA care (n = 978), % Morning stiffness

88.8

Joint exam (complaint focused)

72.8

ESR

68.1

CRP

51.8

Patient global VAS

45.3

Patient pain VAS

43.7

Physician global assessment

41.9

28 joint count

27.1

66 joint count

18.8

HAQ (unscored)

17.7

HAQ (scored)

12.3

DAS (any)

Reducing Treatment Variability Quality of RA care varies by geography,52,53 race,54 treating specialty,39,40 and type of health plan; variation in quality performance exists for commercial, Medicare, and Medicaid population. In an analysis of Medicare managed care members, one study found that the use of DMARD therapy varied considerably by health plan.52 One payer indicated that although some of the variability in smaller health plan performance may be attributed to the small sample size (because of small denominators for certain subgroups of members), similar levels of variation can be found in larger populations as well.

6

ACR20 or ACR-N

1.8

ACR20 indicates American College of Rheumatology 20% criteria for improvement; ACR-N, American College of Rheumatology-N; CRP, C-reactive protein; DAS, Disease Activity Score; ESR, erythrocyte sedimentation rate; HAQ, Health Assessment Questionnaire; RA, rheumatoid arthritis; VAS, visual analog scale. Reproduced with permission from Cush JJ. Biologic drug use: US perspective on indications and monitoring. Ann Rheum Dis. 2005;64: iv18-iv23. Used with permission of the publisher, BMJ Publishing Ltd. All rights reserved.

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The panel participants supported the notion that variability in quality performance was largely a reflection of treatment variability in RA. As discussed before, there is substantial variation in rheumatologist and PCP compliance with DMARD use.37-40 Similarly, PQRS reporting patterns suggest that there is considerable variability in the measurement of RA disease activity and functional status by the rheumatology community, let alone PCPs.38 Although consensus-based clinical guidelines for RA have been in place for many years, significant variation continues to persist in the identification and treatment of RA.39,40,52-54 In addition, the panel payers and panel rheumatologists were generally aligned regarding the need for quality metrics that would support guideline adherence and reduce variability in care. Nevertheless, panel rheumatologists indicated that they would not support such initiatives if they were used to justify limiting their autonomy to practice medicine.

undifferentiated codes made it more difficult to identify member subgroups for quality improvement initiatives and population-based outreach.

Patient Adherence to Treatment Adherence to pharmacotherapy remains an issue in the treatment of patients with RA. Although patient affordability of newer biologics is frequently cited as a potential contributor,55 data suggest that adherence is suboptimal across the spectrum of DMARDs, irrespective of cost.56 In one study, adherence to the DMARD agent methotrexate was only 59%.57 This data has clinical relevance, since high adherence to prescribed methotrexate has been associated with improved outcomes.58 Patient as well as provider accountability were identified as important determinants of quality related to adherence. According to the panel rheumatologists, treating physicians and support staff should closely monitor adherence to prescribed therapies at each office visit. Patients also share the responsibility of adhering to treatment, and accept accountability to remain adherent to their care plan; this view was shared by the panel payers as well as by physicians.

Data Integration and Connectivity Although health information technology has made tremendous advances in the past decade, panelists indicated that these innovations have not necessarily translated into better connectivity and communication. There are a multitude of different electronic health rec­ ord (EHR) manufacturers, most of which are built using proprietary platforms that have limited ability to communicate with other EHR systems. As a result, EHR interoperability remains a major limiting factor in care coordination among different providers and institutions. According to the panel payers, lack of interoperability may also limit payers’ ability to access, compile, and submit data required to satisfy quality reporting requirements. This is complicated by the fact that many payers have not integrated their medical and pharmacy data, and in some cases, these data may be housed in different data systems that do not communicate with each other. Promoting effective communication and coordination of care was identified as one of the key goals of the National Quality Strategy.60 To ensure that institutions are making appropriate use of EHR technology, several meaningful use requirements (in areas such as medical billing, patient records, and employee communication) have been established in accordance with mandates set forth by the ACA.3 Although true integration and advanced connectivity hold tremendous promise in facilitating quality improvement, panelists indicated that progress has been slow, with a great deal of room for improvement. In December 2013, the Patient-Centered Outcomes Research Institute approved $93.5 million to support 29 health data networks in an effort to improve access to a large amount of diverse, nationally representative health information.61

Patient Identification and Coding To receive appropriate care, patients with RA must be identified and diagnosed correctly.59 However, it is estimated that nearly one-third of more than 2.2 million patients with RA have not been diagnosed or treated.21 Anecdotally, some rheumatologists on the panel indicated that they have been referred patients misdiagnosed with RA who were actually suffering from a different condition. Payers have an important stake in the proper identification of patients with RA and coding of disease and treatments, as it can affect quality performance measurement.59 Therefore, it was identified as a determinant of quality. Payers represented on the panel also pointed to the need for accurate, specific coding, noting that the use of

Clinically Meaningful RA Quality Measures According to the panel, the lack of clinically meaningful quality measures tied to outcomes has been a major shortcoming in RA. In many other therapeutic areas, treatment targets have been defined in an effort to improve patient outcomes and limit organ damage associated with poor disease control. However, to this point, no such “treat-to-target” tests similar to those in diabetes or hypertension have reached critical mass in RA treatment by the rheumatology community.41 The lack of a universally accepted clinical indicator in RA has contributed to perceived shortcomings in clinical practice. In the absence of such a metric, there has been a lack of agreement regarding the optimal mea-

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surement tools of functional status and disease activity. The tools that are available have subjective elements, contributing to inter- and intra-assessor variability.62 According to one panelist, the current situation had led to inertia, and some rheumatologists do not measure functional status or disease activity at all. Recently, an international task force evaluated current RA treatment patterns and came to consensus on several recommendations designed to inform patients, rheumatologists, and other healthcare stakeholders about strategies to promote optimal outcomes in RA.63 They concluded that one of the goals of RA treatment should be very low disease activity. To achieve this goal, clinicians should adjust drug therapy quarterly and institute frequent, routine monitoring of disease activity using validated composite measures. Furthermore, the task force recommended that clinicians, in consultation with their patient, should set individualized “treat-to-target” goals, accounting for comorbidities, patient factors, and drug-related risks, and seek to maintain the target throughout the remaining course of the disease. The task force did not specify a universal metric to be used to measure disease activity, indicating that the choice of DAS, DAS28, SDAI, or CDAI should depend on patient factors, including comorbid medical conditions.63 These recommendations underscore the generally accepted notion that a single universally accepted, objective quality metric does not exist for RA. Given the heterogeneity of RA, the best option is for the rheumatology community to agree to measure clinical disease activity on a select group of validated measures.63

ers to pursue NCQA accreditation; participants pointed out that most health plans achieve accreditation status. As a result, accreditation is frequently a baseline expectation from healthcare purchasers and viewed as “the cost of doing business.” According to the panel payers, the cost of NCQA accreditation was substantial in terms of administrative cost and resource utilization. Nevertheless, participants acknowledged that the program contributes positively to quality performance in the clinical setting. As opposed to the NCQA accreditation, there is a considerable incentive for health plans with Medicare members to perform well in the Medicare STAR program, particularly for plans that achieve 5-star ratings for quality measures. However, the panel payers noted that performance in some therapeutic areas, such as diabetes and cardiovascular disease, received far greater bonus compensation than performance in other therapeutic areas. The DMARD measure for RA was cited as one of the lower-compensated STAR measures. One payer noted that his organizations tend to allocate more resources toward quality efforts that are better compensated, particularly if they affect large patient populations. Because the prevalence of and incentives for RA are relatively low, quality initiatives for RA have not been a high priority for payers.

Different Perspectives The interactive dialogue at the panel made it evident that rheumatologists, payers, and employers had significantly different perspectives regarding quality in general and quality of RA care in particular. This fundamental difference was in large part the result of their professional orientation. As treating physicians, rheumatologists serve their individual patients and are entrusted to provide the best possible clinical care in accordance with their professional training and skills. Historically, physicians have not been concerned with the system cost of healthcare, although this has begun to change in recent years. With regard to RA, the panel rheumatologists identified a number of key determinants of quality in RA care, including access to specialty care, adherence to treatment plans, clinically meaningful process measures, and adequate incentives to participate in quality initiatives. In terms of measurement, rheumatologists indicated that there have been a number of technical issues limiting routine assessment of disease activity and functional assessment. For example, physician and patient assessments are relatively subjective and may differ. Likewise, there is inter- and intra-observer variability in clinician joint-count measurement.62 Panel rheumatologists also specified that measurement may be affected by non-RA

Adequate Incentives for Quality Program Participation Panelists questioned the current incentive structure for participation in the NCQA and PQRS programs. Despite the administrative costs of program participation, physicians are facing declining incentives to participate in the PQRS. Although the program remains incentive-based in 2014,64 the initial 2% bonus on Medicare Part B revenues had fallen to 0.5% in 2012.65 Beginning in 2015, CMS will apply a 1.5% penalty to eligible physicians who do not satisfactorily report data on quality measures for covered care services.64 Although this negative incentive may drive increased participation in the PQRS program, the panel rheumatologists indicated their opposition to the approach used by CMS. In addition, the panel payers expressed that they have a very limited stake in the PQRS, because there is no incentive for them to encourage their network physicians to participate in the program. Furthermore, there is no monetary incentive for pay-

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factors, such as other comorbid causes of pain (ie, fibromyalgia or osteoarthritis). Disease severity is also an issue; functional status evaluations have limited utility for patients with more advanced disease, particularly if significant joint damage has already occurred. Despite these challenges, however, the panel rheumatologists acknowledged the existence of a substantial unmet need to improve quality of care for patients with RA. Payers have a markedly different mission from that of practicing physicians. They are charged with managing populations of patients, as well as their premium dollars. Therefore, payers view quality from a broader perspective, with an orientation toward value-based care that balances clinical and economic considerations. Health plans have limited resources and typically focus on quality initiatives that are expected to have a positive shortterm impact on a reasonably large, well-defined population and/or have the potential for significant cost savings to the plan. Although the panel payers viewed RA as a relatively high-cost condition (on a per-affected member basis), a number of barriers, including a poorly defined population (including a sizable number of undiagnosed and misdiagnosed patients or miscoded diagnoses), relatively low hospitalization rates, and a lack of incentives, were all cited as reasons why payers do not focus on RA. Consequently, there are virtually no quality improvement initiatives specific to RA in place at this time, and many payers are primarily concerned with the cost of newer biologic therapies used to treat RA. According to one participant, biologics are relatively undifferentiated clinically, with a lack of data from head-to-head trials. Because payers are not convinced about the link between biologic use and quality (ie, improvement in outcomes), they concentrate their resources on minimizing cost exposure (ie, contracting, utilization management of RA treatments). To employers, clinical quality measures are only important insofar that they translate into outcomes. In RA, the employer community is interested in the link between clinical quality and improved productivity, presenteeism, and functionality. According to the employer representative on the panel, there are a number of validated productivity scales, but they are not widely used in clinical practice. Furthermore, there are insufficient data to quantify the link between productivity and quality of RA care. As a result, current RA quality measures have limited utility for employers. Therefore, better productivity studies are needed to quantify the scope of the problem and the potential savings that could be generated by quality improvement/disease management programs in RA.

Charting a Path Forward Although physicians, payers, and employers viewed

quality of RA care very differently, areas of common ground began to emerge during the interactive panel discussion. Conceptually, panelists agreed that the value proposition for improving quality of RA care needed to be better defined and effectively communicated to physicians, payers, employers, and patients. Currently, RA quality efforts are largely viewed as an esoteric exercise intended to satisfy regulatory and accreditation requirements. As a result, there is a perceived disconnect between participation in existing CMS and NCQA quality improvement initiatives versus the organic, mission-driven efforts of rheumatologists and payers to optimize care at the patient and population levels, respectively. All stakeholders need to be convinced that RA quality improvement efforts translate into tangible benefits for patients and, by extension, providers, payers, and group purchasers of healthcare. To move forward, the panel agreed that although the DMARD therapy measure may have served a useful purpose as a starting point in RA quality measurement, the time has come to evolve. To that end, there was overall agreement that measures of disease activity, and to a lesser degree, functional status, would serve as more clinically relevant indicators of quality of RA care. According to the panel rheumatologists, disease activity—as measured by the DAS, CDAI, SDAI, RAPID3, and other validated scales—is a clinically meaningful indicator; can be measured relatively easily by a trained specialist; and perhaps most important, is a useful predictor of disease progression and health outcomes. The panelists acknowledged that a wide number of tools are currently being used to measure disease activity, and recommended that stakeholders come to a consensus on 1 or 2 key measures to reduce variation in measurement and performance. Routine measurement of disease activity and functional status will require physician education. According to the panel participants, it is possible to overcome the technical challenges that have hampered measurement of clinical indicators in RA. For this to happen, however, rheumatologists must be educated to understand the true value of routine measurement in and follow-up of patients; essentially, rheumatologists must be convinced that their efforts will translate into improved care and patient outcomes. The panel payers and the panel rheumatologists also agreed that improved PCP education can improve the quality of RA care. In particular, they seek more consistent referrals of properly diagnosed patients. It was noted that some PCPs may be reluctant to refer patients to a rheumatologist, even though these patients may require the care of a physician with specialized training. Proper identification, diagnosis, and coding were all mentioned as

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areas of concern for PCPs treating patients. Payers were particularly aware of perceived shortcomings of RA care by PCPs in areas with limited access to specialty providers. The panelists agreed that there were significant opportunities for collaboration among clinicians, payers, employers, quality measure developers, and others, including pharmaceutical and biotech manufacturers, with a stake in the quality of RA care. For example, aside from developing and commercializing new therapies for RA, manufacturers can continue to play an important role in disease education. In addition, there is opportunity to collaborate with the rheumatology community and payers to develop tools that facilitate quality measurement and reporting. Use of social media such as www.creak joints.org, which has more than 55,000 members, is one available tool to engage patients with arthritis and disseminate information about the quality of RA care.66 Going forward, all parties agreed that efforts to improve quality must be strategic, focused, sustained, and perhaps most importantly, account for the patient perspective at all times.

quality; however, greater impetus is needed to stimulate the process. Although the panel generated positive discussion and a number of good ideas and recommendations, there was insufficient consensus to begin building a framework for advancing the quality of RA care. Nevertheless, the program served as a valuable starting point in identifying the issues, challenges, and barriers to improvement. n Author Disclosure Statement Dr Curtis, who is an employee of the University of Alabama at Birmingham, received financial support from Pfizer in exchange for his role as a speaker and participant on the Rheumatoid Arthritis Quality Expert Medical Panel. Dr Kwoh, who is an employee of the University of Arizona, received financial support from Pfizer in exchange for his role as a speaker and participant on the Rheumatoid Arthritis Quality Expert Medical Panel. Dr Rizzoli, who is a former employee of Presbyterian Health Plan, received financial support from Pfizer in exchange for his role as a speaker and participant on the Rheumatoid Arthritis Quality Expert Medical Panel. Mr Welz, who is an employee of The Lynx Group, was a paid consultant to Pfizer in connection with the development of this manuscript.

Conclusion Overall, the panel served as an effective vehicle to bring together multiple stakeholders who affect the quality of RA care. According to the panel, the current RA quality landscape can be summarized by the following: • As it is currently constructed, the DMARD therapy measure is not adequate to measure quality or drive performance improvement • Without agreement on clinically meaningful indicators of disease, there could be little momentum to improve quality of RA care • At the current time, payers see little incentive or reason to focus on RA • Certain system issues, such as access to rheumatologists and clinically appropriate referral patterns, are thought to have an impact on quality • More foundational work on measures, incentives, and clinician education is necessary in order for RA quality to gain traction. In alignment with the data, the panel conceptually agreed that there was considerable room for improvement in identifying, treating, and managing patients with RA. However, the rheumatology community has encountered significant challenges in agreeing on a platform that best characterizes and supports quality improvement in RA. Furthermore, payers and rheumatologists differed significantly in their perceptions of how to advance the RA quality agenda. The panelists spoke at length about the reasons for these challenges, and offered a number of potential solutions to help move the agenda forward. The panel indicated a desire to collaborate on RA

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