Application of explicit process of care measurement to rheumatoid arthritis: Moving from evidence to practice

Abstract

Objective. To construct quality measures with measurement validity and meaning for clinicians. Methods. We conducted a prospective cohort study of rates of change in disease-modifying antirheumatic drug (DMARD) and/or systemic corticosteroid drug or dose for 568 patients with rheumatoid arthritis (RA) across 6,159 clinical encounters within 12 months to examine how changes in clinical specifications change adherence. Results. Rates of DMARD change were sensitive to specifications regarding the intensity of disease activity (severe or moderate), duration of specified disease activity, and length of the observation period. Over 12 months, the proportions of 377 patients with severe disease activity observed for 1-month, 2-month, and 3-month time blocks who had a change in DMARD drug or dose were 36%, 57%, and 74%, respectively. Over 12 months, a change in DMARD drug or dose was observed for 44%, 50%, and 68% of 377 patients with severe disease within 3 months, 6 months, and 12 months, respectively, of the patient meeting criteria for severe disease activity. A change in DMARD drug or dose was observed for 21%, 23%, and 34% of 149 patients with moderate disease activity within 3, 6, and 12 months, respectively, of the patient meeting criteria for moderate disease activity. Conclusion. Rates of pharmacologic interventions for patients with moderate and severe RA disease activity vary substantially by intensity and duration of disease activity and by duration of period for observing change. Lack of precision in explicit process criteria could substantially mislead comparisons of quality of care across comparison groups.

Symptom management after breast cancer treatment: is it influenced by patient characteristics?

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Epitope‐specific immunotherapy of rheumatoid arthritis: Clinical responsiveness occurs with immune deviation and relies on the expression of a cluster of molecules associated with T cell tolerance in a double‐blind, placebo‐controlled, pilot phase II trial

“…The rapid evolution of molecular immunology has changed the way we conceptualize the pathogenesis and treatment of this disease. With the advent of targeted therapies, specific biologic interference with pathogenic pathways, including cytokines and costimulatory molecules, is complementing, and in some cases replacing, generalized immune suppression with cytotoxic drugs or antimetabolites (2–8). Consequently, the focus in clinical research is veering toward early aggressive intervention to achieve remission or low disease activity and to prevent the development of joint erosions and functional limitations.…”

“…For instance, the different effects exerted by various anti–tumor necrosis factor α (anti‐TNFα) agents on Treg cells were recently reported (20–22). However, tolerization effects from current biologic agents appear to depend on continuous administration; in most cases, clinical control fades with withdrawal of therapy (2–8).…”

Quality measurement and improvement in rheumatology: Rheumatoid arthritis as a case study

“…This process measure is in part based on objective outcomes: disease activity and radiographic progression. Several studies have assessed performance on this process of care, with adherence ranging from 50% to 85% (43–45). Important lessons in the specification of this measure have become apparent: variation in measure performance may relate to the level of disease activity (moderate or severe), the duration of time a patient is at a disease activity level (months), and time allotted to the rheumatologist for an intervention to occur (43).…”

“…Several studies have assessed performance on this process of care, with adherence ranging from 50% to 85% (43–45). Important lessons in the specification of this measure have become apparent: variation in measure performance may relate to the level of disease activity (moderate or severe), the duration of time a patient is at a disease activity level (months), and time allotted to the rheumatologist for an intervention to occur (43). That is, if a patient has severe disease activity that is sustained over a longer period of time, or if this measure is assessed at 6 months rather than 3 months, performance on the measure will likely be higher.…”