1. CRA Guidelines for the Management of Rheumatoid Arthritis- Update May 25, 2013 Pooneh Akhavan, MD

2. 1- Describe the CRA's multi-faceted approach to disseminate the RA recommendations 2- Understand the process of moving from RA guidelines to RA Quality Indicators 2 Learning Objectives

3. CRA recommendations were supported by the CIHR and matched funds from the CRA Disclosures

4. CRA Recommendations for RA Management J Rheum 2012

5.  Part 1: Treatment – 26 recommendations RA management strategies (6) Glucocorticoids and traditional DMARDs (8) Biologic DMARDs (12)  Part 2: RA drug safety – 13 recommendations Perioperative management (2) Screening for LTBI prior to biologic therapy (4) Optimal vaccination practices (3) Treatment of RA patients with a history of malignancy (4) CRA Recommendations for RA

6. 1. Yes, read Part I: Treatment 2. Yes, read Part II: Safety 3. Yes, read both parts I and II 4. No Have you read the recommendations? CRA Annual Meeting 2013- Ottawa

7. Dissemination activities Moving towards the Quality Indicators Presentation Outline

8. Dissemination

9. Overview Dissemination Activities  Completed 1.Publications (open access J Rheum / CRA website) 2.Presentations (Local, regional, national international) 3.Additional tools for download (CRA website) 4.CRA guideline self-evaluation survey followed by CRAJ question and answer series (Summer 2013)  In progress 1.MDbriefcase eRecommendation program (CME accredited) 2.EMR integration  In future Multi-disciplinary RA guideline dissemination workshop September 2013

10. 1. Dissemination Activities-Completed Download RA guideline documents Download RA algorithms & slide decks http://rheum.ca/en/publications/cra_ra_guidelines

11. Dissemination Activities-Completed 2. Presentations at rheumatology meetings: International: ACR, EULAR National: CRA, PANLAR Regional meetings: WAR, ORA, SOAR, Laurentian Various local meetings 3. Slide decks as self-teaching tools and/or for presentations at local rounds and other educational activities (www.rheum.ca/en/publications/cra_ra_guidelines)

12. Dissemination Activities- Completed 4. CRA self-evaluation survey: - 24 questions - CRA membership - April-May 2013 - 188 of 432 responded - CRAJ series (to start this Summer)

13. 1. MDbriefcase eRommendation program (will be CME accredited) Dissemination Activities- In Progress TREATMENT ASPECTS SAFETY ASPECTS

14. Dissemination Activities- In Progress 2. Ongoing discussions with eHealth Ontario - EMR Integration of selected key recommendations to measure performance

15. Dissemination Activities- In Future CIHR meeting grant approved Objectives: a) Discuss barriers and local adaptation issues from knowledge users (clinicians, therapists, pharmacists, nurses and patients) b) Create a plan for targeted messages for each knowledge user group c) Start the process of identifying the Quality Indicators from the guidelines Interdisciplinary Dissemination and Local Adaptation Workshop (RA Guidelines) September 2013

16. Overview Dissemination Activities  Completed 1.Publications (open access J Rheum / CRA website) 2.Presentations (Local, regional, national international) 3.Additional tools for download (CRA website) 4.CRA guideline self-evaluation survey followed by CRAJ question and answer series (Summer 2013)  In progress 1.MDbriefcase eRecommendation program (CME accredited) 2.EMR integration  In future Multi-disciplinary RA guideline dissemination workshop September 2013

17. Dissemination activities Moving towards the Quality Indicators Presentation Outline

18. Development of Canadian Quality of Care Indicators for RA

19. Developing QIs Define the optimal standard of care Define the minimally acceptable standard of care Quality Indicators Clinical Practice Guidelines

20. Definitions Quality Measure Measures the performance Has detailed specifications (numerator/denominator) Number of eligible patients receiving a process of care (×100) Number of patients eligible for a process of care Example: “the percentage of patients age 18 and older who were prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD during the 12-month reporting period”

21. Another Example: TB screening Numerator Patients with a TB screening within six months prior to receiving a first course of a biologic DMARD Denominator Patients  18 years with RA and receiving a first course of a biologic DMARD Denominator Exclusions Medical reason for not screening for TB – Patient positive for TB and documentation of past treatment – Patient who has recently completed a course of anti-TB therapy

22. Evolution of Quality of RA Care R HEUMATOID A RTHRITIS G UIDELINES

23. Evolution of Quality of RA Care R HEUMATOID A RTHRITIS G UIDELINES R HEUMATOID ARTHRITIS QUALITY MEASUREMENT & I MPROVEMENT

24. From RA Guidelines to QIs ACR 2012 RA QIsCanadian QIs- In progress To develop evidence- and consensus-based quality indicators for the care of Canadian adults living with RA using current CRA guidelines 1.Assessment of Disease Activity 2.Assessment of Functional Status 3.TB testing 4.Treatment with DMARDs 5.Administration of influenza vaccine 6.Administration of pneumococcal vaccine 7.CBC, Cr and LFT check

25. For any queries/ comments about CRA recommendations for RA, please contact raguidelines@rheum.ca Acknowledgment Dr. Pooneh Akhavan Dr. Vivian Bykerk Dr. Claire Bombardier Mrs. Anne Dooley Dr. Paul Haraoui Dr. Glen Hazlewood Dr. Majed Khraish Dr. Sharon LeClercq Mr. Jean Légaré Dr. Diane Mosher Dr. James Pencharz Dr. Janet Pope Ms. Orit Schieir Dr. John Thomson Dr. Carter Thorne Dr. Michel Zummer RA Guidelines Working Group CRA On-line Survey Dr. Sanjay Dixit