Integrating Quality Measures for RA into Your Practice: Optimizing Patient Care Using Your Own Data

Transcription

1 Integrating Quality Measures for RA into Your Practice: Optimizing Patient Care Using Your Own Data Robin K. Dore, MD Clinical Professor of Medicine David Geffen School of Medicine at UCLA Los Angeles, CA

2 Disclosure of Potential Conflicts of Interest It is the policy of Cedars-Sinai Medical Center to ensure balance, independence, objectivity, and scientific rigor in all of its educational activities. Cedars-Sinai Medical Center assesses conflict of interest with its faculty, planners and managers of CME activities. Conflicts of interest that are identified are resolved by reviewing that presenter s content for fair balance and absence of bias, scientific objectivity of studies utilized in this activity, and patient care recommendations. While Cedars-Sinai Medical Center endeavors to review faculty content, it remains the obligation of each physician or other healthcare practitioner to determine the applicability or relevance of the information provided from this course in his or her own practice. In accordance with the policy of Cedars-Sinai, faculty are asked to disclose any affiliation or financial interest that may affect the content of their presentations.

3 Learning Objectives Identify changes in ACR guidelines for rheumatoid arthritis (RA) Describe how quality of care for patients with RA is currently assessed in one s practice Identify quality data from one s practice that are being reported and locate a summary of the results Formulate a plan for improving key aspects of care being provided to patients with RA

4 Activity Overview Part 1: 30-minute lecture New ACR guidelines Quality assessment what s out there, how can the data be used to inform where practice can be improved Part 2: 60-minute workshop Reflect on local quality processes Share best practices Locate and use your data to improve patient care

5 Please Complete the Pretest Now (Keep packet stapled together)

6 Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

7 2015 ACR Treatment Guidelines: What is Covered? 1. Use of traditional DMARDs, biologic DMARDs, and tofacitinib a. Tapering and discontinuing medications b. Treat-to-target approach 2. Use of glucocorticoids 3. Use of biologics and DMARDs in high-risk populations 4. Use of vaccines in patients starting/receiving DMARDs or biologics 5. Screening for TB 6. Laboratory monitoring for traditional DMARDs Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

8 2015 ACR Treatment Guidelines: What is New? GRADE methodology Early RA Patients Established RA patients High-risk comorbidities Congestive heart failure Hepatitis B Hepatitis C Previous malignancies Serious infection Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

9 Recommendation for Early (and Established) RA Patients Treat-to-Target strategy Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26. Low disease activity or remission

10 Recommendations for Early RA Patients DMARD monotherapy (MTX preferred) recommended over double or triple DMARD therapy > Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

11 Recommendations for Early RA Patients With Moderate or High Disease Activity (Despite DMARD Therapy) Combination of DMARDs or TNFi or non-tnf biologic, +/- MTX > Continuing DMARD monotherapy alone Biologic therapy should be used with MTX over biologic monotherapy, when possible, due to superior efficacy. Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

12 Recommendations for Early RA Patients With Moderate-or High-disease Activity Despite DMARD or Biologic Therapies Conditional recommendations Add low-dose glucocorticoids (prednisone or equivalent 10 mg/day) Add short-term glucocorticoids (< 3 mo) for flares Lowest possible dose Shortest possible duration Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26. Prednisone

13 Treating Early RA Duration < 6 months Strong Conditional Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

14 Recommendations for Established RA Patients For DMARD-naïve patients with low disease activity, we strongly recommend using DMARD monotherapy over a TNFi. TNF Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26. Woodrick RS, Ruderman EM. Nat Rev Rheumatol. 2011;7(11): Accessed Feb 2016.

15 Recommendations for Established RA Patients For moderate-or-high disease activity (despite DMARD monotherapy), we strongly recommend Combination DMARDs or Adding a TNFi or a non-tnf biologic or tofacitinib (all +/- MTX) Biologic therapy should be used in combination with MTX over biologic monotherapy > Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

16 Recommendations for Established RA Patients For moderate or high disease activity despite TNFi monotherapy: One or two DMARDs should be added to the TNFi therapy + TNFi DMARD(s) Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

17 Established RA With Low Disease Activity (Not Remission) Continue DMARD therapy, TNFi, non-tnf biologic or tofacitinib Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

18 Established RA in Remission Strong recommendation against discontinuing all therapies Conditional recommendation for tapering Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

19 Treating Established RA Duration 6 months or 1987 ACR classification criteria Strong Conditional Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

20 TB Screening 2015: Tofacitinib included Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

21 Quality Assessment and Reporting PQRS Quality Measures

22 DMARD Therapy PQRS Measure # 108 Percentage of patients aged 18 years and older who were diagnosed with RA and were prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD. Evidence: Extensive evidence reflected in ACR and EULAR guidelines that treatment has a positive impact. ACR: Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26. EULAR: Smolen JS, et al. Ann Rheum Dis. 2014;73:

23 Tuberculosis Screening PQRS Measure # 176 Percentage of patients aged 18 years and older with a diagnosis of RA who have documentation of a TB screening performed and results interpreted within 6 months prior to receiving a first course of therapy using a biologic diseasemodifying anti-rheumatic drug (DMARD). Evidence: TNF inhibitors increase the risk of both TB and other granulomatous infections. The number of cases of TB was dramatically reduced after screening became standard of care. Woodrick RS, Ruderman EM. Nat Rev Rheumatol. 2011;7(11):

24 PQRS Measure # 177 Periodic Assessment of Disease Activity Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment and classification of disease activity within 12 months. Rationale: After establishing a diagnosis of RA, risk assessment is crucial for guiding optimal treatment. For the purposes of selecting therapies, physicians should consider the patient s disease activity (low, moderate, or high) at the time of the treatment decisions. Accessed January 2016.

25 Assessing Disease Activity Instrument Acronym Range Remission Routine Assessment of Patient Index Data 3 RAPID Clinical Disease Activity Index CDAI Disease Activity Score 28 (ESR) DAS < 2.6 Simplified Disease Activity Index SDAI Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

26 PQRS Measure # 178 Functional Status Assessment Percentage of patients aged 18 years and older with a diagnosis of RA for whom a functional status assessment was performed at least once within 12 months. ACR Recommendations: Functional status assessment using a standardized, validated measure should be performed routinely for RA patients, at least once per year. Examples: Health Assessment Questionnaire Health Assessment Questionnaire II Multidimensional Health Assessment Questionnaire PROMIS Physical Function 10-item, 20-item PROMIS Physical Function Computerized Adaptive Tests (PROPFCAT) Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26. Maska L, et al. Arthritis Care Res (Hoboken). 2011;63 Suppl 11:S4-13.

27 PQRS Measure # 179 Assessment and Classification of Disease Prognosis Percentage of patients aged 18 years and older with a diagnosis of RA who have an assessment and classification of disease prognosis at least once within 12 months. Evidence: Similar to #177; ACR Content and Voting Panels agreed that disease prognosis was largely captured in the concept of disease activity and that information regarding prognosis was unlikely to further contribute to decisionmaking. Singh JA, et al. Arthritis Rheumatol. 2016;68(1):1-26.

28 Glucocorticoid Management PQRS Measure # 180 Percentage of patients aged 18 years and older with a diagnosis of RA 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. Evidence: Addition of low-dose glucocorticosteroids to synthetic DMARDs improves structural outcomes, decreases inflammatory markers and reduces symptom severity in RA patients. Kavanaugh A, Wells AF. Rheumatology (Oxford). 2014;53(10):

29 Local Practice Quality assessment reporting: who reports what? Data flow: does the quality report accurately reflect clinical practice? Gap between clinical practice and reporting: where is the information lost? (non-entry, wrong entry, limitations of EHS?) Feedback on quality measures. What information do clinicians receive? Closing the loop: How can the reporting process be harnessed to improve patient care?

30 Summary Changes in ACR guidelines may have implications for clinical management Quality measures are based on clinical experience and guidelines Current quality measures are reporting measures, not patient outcome measures How can data from reported quality measures benefit patient care?

31 Integrating New ACR Guidelines for RA into Your Practice: Optimizing Patient Care Using Your Own Data Interactive Workshop

32 Learning Objectives Describe how quality of care for patients with RA is currently assessed in one s practice Identify quality data from one s practice that are being reported and locate a summary of the results Formulate a plan for improving key aspects of care being provided to patients with RA

33 Implementation Workshop Agenda 5 Introduction 5 Individual reflection on quality of care in your practice 10 Small group discussion 10 Facilitated large group discussion 10 Commitment to change (individual), Evaluation

34 5 MINUTES STEP 1: QUALITY MEASURES SURVEY Reflect on Quality Measures in your practice Work on your own to think about quality measures in your practice and barriers that impede optimal patient care. Record your thoughts on the Step 1 handout

35 Small Group Discussion Please Break Into Work Groups With your neighbor, turn around and form a team of 4 with the two neighbors behind you If you are not matched up with a group, join a group that is closest to you Goal is groups of 4-6

36 10 MINUTES Small Group Discussion Discuss your issues and experiences in your group Assessment of quality of care Reporting Data feedback Improving quality of care Describe your situation What was your approach? What difficulties did you face? What were the results/impact of your effort? (Record your groups stories on the worksheet)

37 5 MINUTES Group Activity Moderated discussion on quality assessment, reporting, barriers, and approaches Show of hands: How many of you are actively involved in quality reporting? How many of you have received feedback on quality measures? How many of you have been able to use quality data to improve patient care? Who has a story of how you were able to translate quality measures into clinical practice?

38 10 MINUTES Group Review of Barriers Are there barriers that can be overcome to improve the quality of care provided to patients with RA? Is there a group that discussed this that would like to share their story?

39 5 MINUTES STEP 2 ACTION PLAN Individual Commitment to Change Which barrier in your practice will you address? Use the SMART framework to create your goal What are the first steps you will take? Record your thoughts on the Step 2 worksheet

40 3 MINUTES Choose an Accountability Partner From Your Small Group Invite a partner Share contact information on form provided Phone Project title Commit to follow-up with specific date

41 2 MINUTES Conclusions Moderator to capture essence of discussion Major themes in quality assessment & reporting Common barriers Highlight useful/innovative solutions Best practices for applying quality assessment to patient care

42 Please Complete the Posttest Now

43 Please Complete and Return 1. STEP 1 handout 2. STEP 2 Keep the top sheet, return the carbon copy of your action plan 3. Pretest/posttest 4. Activity evaluation

44 Tools and Resources ACR guidelines Singh JA, et al. Arthritis Rheumatol. 2016;68(1): PQRS measures for RA 2015 Physician Quality Reporting System (PQRS) Measure Specifications Manual for Claims and Registry Reporting of Individual Measures

45 Thank you! For more education please visit: