1. Measuring Quality of Care in People with Arthritis Sarah Sampsel, MPH National Committee for Quality Assurance AcademyHealth 2004 ©2004 by the National Committee for Quality Assurance

2. Introduction Arthritis and other rheumatic conditions –Leading cause of disability among adults in the United States –Early intervention could reduce chronic symptoms –Highest utilizers of NSAIDs –Often receive suboptimal care to treat symptoms –Potential for improvement with standardized measurement

3. Objectives Assess Desirable Attributes (HEDIS ® ) (selected) –Feasibility: barriers to implementation –Validity: age limits, exclusions, diagnoses –‘Actionability’: variation in performance across plans and geographic regions

4. Methods Multi-disciplinary expert panel Volunteer testing by health plans Abstraction from administrative and medical record data

5. Arthritis Measures % of patients screened for pain and functional status % with osteoarthritis with recommendations for weight loss, physical activity, acetaminophen use % of high risk patients using non-steroidal anti- inflammatory drugs (NSAIDs) and receiving gastrointestinal prophylaxis % of patients with rheumatoid arthritis receiving a disease modifying anti-rheumatic drug (DMARD)

6. Principal Findings Arthritis symptom assessment: documentation of assessment of pain and functional status DiagnosisArthritis Prevelance/1000 Pain Assessment Functional Assessment OAC = 1.8 M+C = 14.1 Md = 0.2 82.9%56.1% RAC = 1.4 M+C = 7.3 Md = 0.2 77.0%57.7% Other Inflammatory C = 0.3 M+C = 0.7 Md = 0.0 67.0%55.3% C = Commercial; M+C = Medicare + Choice; Md = Medicaid

7. Principal Findings PlanWeight Loss* Physical Activity Acetaminophen A33.3%41.2%16.7% A – Medicare35.0%22.2%15.1% B57.9%43.5%14.0% Osteoarthritis care: documentation of recommendations for weight loss and physical activity, acetaminophen use *Credit given for members with BMI 27 kg/m2 and a documented recommendation for weight loss OA Prevalence/1000 members: Commercial: 1.2; Medicare + Choice: 78.1

8. Principal Findings Plan% Adult Members with NSAID Rx % high risk patients with GI prophylaxis A11.9%22.6% A – M+C26.0%14.3% B12.2%34.2% C13.5%40.8% C – Md5.3%35.3% Appropriate gastrointestinal prophylaxis for high risk patients utilizing prescription NSAIDs C = Commercial; M+C = Medicare + Choice; Md = Medicaid

9. Principal Findings PlanRA Prevalence/1000 CommercialMedicaidMedicare AC = 0.8 M+C = 5.4 67.6%N/A71.4% CC = 2.1 Md = 1.1 75.8%76.5%N/A Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis C = Commercial; M+C = Medicare + Choice; Md = Medicaid Only measure with potential for HEDIS inclusion Use of Biologic DMARD Therapies <11% of prescriptions

10. Summary of Findings Administrative data unreliable for identification of osteoarthritis cases –Expected prevalence: 15 - 20% –Field-Test: 1% (Comm.), 8% (Medicare + C) –Potential under-coding and under-reporting Enormous potential for improvement –Documentation of services that were provided

11. Summary of Findings Challenges for measure implementation –Lack of medical record documentation –Unable to locate documentation of many aspects of care measured –Inconsistency of documentation –Lack of standardized instruments to assess pain and functional status

12. Implications Performance measures create a powerful tool for quality improvement and delivery system comparisons Quality of care improvement in arthritis will require better coding of diagnosis and documentation of care rendered

13. Musculoskeletal Workgroup Teresa Brady, PhD –CDC Arthritis Program John Klippel, MD –Arthritis Foundation Catherine MacLean, MD, PhD –UCLA/RAND John Mason, PhD –BCBS of Massachusetts Kenneth Saag, MD, MSc –University of Alabama at Birmingham, CERTS Khaled Saleh, MD, MSc, FRCSC –Univ. of Minnesota Daniel Solomon, MD, MPH –Brigham & Women’s Hospital Jeffrey Susman, MD –Univ. of Cincinnati Patricia Venus –Center for Health Care Policy and Evaluation Neil Wenger, MD –UCLA Supported in part b y: Janssen Pharmaceutica, Merck & Company, Purdue Pharma, Pfizer Inc., Amgen

14. Acknowledgements Co-Authors: –Catherine MacLean, MD, PhD; RAND Health and UCLA Division of Rheumatology –Philip Renner, MBA; National Committee for Quality Assurance –Russell Mardon, PhD; National Committee for Quality Assurance Project was a partnership between NCQA and the Arthritis Foundation, and built upon work conducted by RAND Health/University of Alabama at Birmingham: Arthritis Foundation Quality Indicator Project (AFQuIP) –MacLean CH, et al. Measuring Quality in Arthritis Care: Methods for Developing the Arthritis Foundation’s Quality Indicator Set. Arthritis Care & Research. 2004;51(2):193-202.