ARLINGTON, VA.—The ACR held its third annual Quality Stakeholders’ Summit in September to get an update on how different groups within healthcare are addressing quality improvement and the national quality movement. The summit included presentations from six medical societies, as well as from vendors and insurers. Some of the invited societies have organizational experience developing measures, while others are now working with members to implement data collection and reporting.
Most medical specialty societies—including the ACR—are actively dealing with these issues on behalf of their members, and “this is our first effort to begin to cross-pollinate with each other,” says Stanley Cohen, MD, clinical professor of rheumatology at the University of Texas Southwestern Medical School in Dallas and president-elect of the ACR.
“Physician specialty societies are the natural home for developing [quality] guidelines,” says Timothy Ferris, MD, MPH, medical director of Massachusetts General Physicians Organization at Massachusetts General Hospital in Boston. The ACR agrees, taking the position that rheumatologists should define what true quality care for rheumatic disease patients looks like rather than having it defined for them by those outside the subspecialty.
“Although some rheumatologists are hesitant about the adoption of new quality measures, it serves the specialty well to pay attention to them,” says Daniel Solomon, MD, MPH. Dr. Solomon is associate professor of medicine and chief of clinical research in rheumatology at Brigham and Women’s Hospital in Boston, chair of the ACR’s Committee on Quality of Care, and a member of The Rheumatologist’s editorial board.
“Because of measure gaps in the quality of care, there is a real need to measure performance. While there are some rheumatologists who have already accepted this, others are more reluctant,” says Dr. Solomon.
CMS is not the only organization to track quality and outcomes via its pay-for-performance program (P4P) and the Physician Quality Reporting Initiative, which allowed physicians to choose from approximately 120 quality measures in 2008. Some insurers are using physician performance “report cards,” and some hospitals are undertaking large-scale efforts with their physicians to measure outcomes. Groups such as the National Committee for Quality Assurance, which had a presence at the summit, work with physicians who want to proactively show their superior care through performance measurement with the use of evidenced-based standards.
The Institute of Medicine’s reports, “To Err Is Human”1 and “Crossing the Quality Chasm,”2 turned the public’s eye on quality indicators, notes Dr. Ferris.
Physician specialty societies are the natural home for developing [quality] guidelines.
— Timothy Ferris, MD, MPH
The ACR’s Quality Tools
In an effort to help its members deal with the challenges they face in measuring, improving, and reporting the quality of the care they deliver, the ACR will debut an online management tool called the Rheumatology Clinical Registry (RCR) in early 2009. The RCR will help rheumatologists measure their performance in nearly 20 areas that pertain to rheumatoid arthritis (RA), osteoarthritis, osteoporosis, gout, and drug safety, says Dr. Solomon.
Dr. Solomon acknowledges the challenge that rheumatology faces compared with other specialties, such as cardiology, which can easily use more specific performance-based outcomes. “Quality is hard to define and measure in rheumatology. Pain and function are not as black and white as event-driven [care],” he says. In addition, “much of rheumatology is not strictly evidence based, and the process measures are not always clearly linked to outcomes.”
Some examples of quality measures under each of the current areas on the ACR’s clinical registry include:
- RA: History and Exam. If a patient has a confirmed diagnosis of RA, then a measure of each of the following should be documented within three months of diagnosis and at least annually thereafter: joint exam, functional status assessment, acute phase reactant, measurement of pain, physician global assessment, and patient global assessment.
- Osteoporosis: Counseling for Vitamin D and Calcium Intake and Exercise. Percentage of patients, regardless of age, with a diagnosis of osteoporosis who either received both calcium and vitamin D or had documented counseling regarding both calcium and vitamin D intake and exercise at least once within 12 months.
- Gout: Allopurinol Adjustment for Renal Function. If a patient with gout is receiving an initial prescription for allopurinol and has significant renal impairment (defined as a serum creatinine level greater than or equal to 2 mg/dl or measured/estimated creatinine clearance less than or equal to 50 ml/min), then the initial daily allopurinol dose should be less than 300 mg a day.
- Drug Safety: Prophylaxis for Patients at Risk for Gastrointestinal Bleeding. If a patient is treated with 1) a nonselective nonsteroidal anti-inflammatory drug (NSAID) or 2) a COX-2 selective NSAID plus aspirin, and the patient has risk factors for upper gastrointestinal bleeding, then the patient should be treated concomitantly with either misoprostol or a proton pump inhibitor unless the patient refuses.
The RCR, which was demonstrated at the summit, underwent pilot testing this year and will have a limited launch in January 2009. It is slated for a full launch to ACR members by June 2009, says Dr. Solomon. Because CMS will now allow registry in addition to claims-based reporting for PQRI, RCR users will be able to more easily report on measures for the 2009 PQRI incentive payment.
The clinical registry will allow for flexible data collection via paper, Web, or even PDA. To make data reporting easier, a practice will only need to report its data on, for example, osteoporosis once and the registry will automatically parse the practice’s performance along four different quality measures, Dr. Solomon explains.
The clinical registry will also provide physicians with a performance report. For example, with this registry you could determine the percentage of your patients with osteoporosis using a particular drug, compared with patients from practices from across the country. “We envision as the tool grows, it’ll give us information with a research role, as well as challenges,” says Dr. Solomon.
Although the ACR hopes that its members will opt to participate in quality measurements for the sake of stronger patient care, Dr. Solomon says that financial incentives provided by CMS and perhaps other payers will likely also drive participation. The ACR’s Rheumatology Clinical Registry will be expanded and improved over time, but the College wants to get its members proactively involved in the process. “We are at an early phase and our system of measuring quality is not perfect,” says Dr. Solomon. “The ACR is being proactive—developing quality measures and tools for practitioners. The quality measures and the systems for collecting data will improve over time.”
Other Approaches to Quality Improvement
Other societies that have had some success in their efforts to develop and implement quality measures shared some of their experiences and advice at the summit, including the American Medical Association. Medical society guests included the American Society of Clinical Oncology (ASCO), the American College of Cardiology, the American Society of Plastic Surgeons, and the American Academy of Neurology.
“We’re not alone in this,” says Dr. Solomon. “Many groups already have experience with quality measures.”
Each group addressed common issues faced during the development of quality measures, including cost (which can be substantial), the need to develop measures that are meaningful to and feasible for physicians, and the desire to keep data confidential.
These specialty societies have seen their quality programs grow. For example, at ASCO, almost 190 practices participate in the group’s Quality Oncology Practice Initiative, says Kristen McNiff, ASCO’s quality division director. ASCO had 37 measures until 2005; by spring of 2008, they had more than 75 measures from which oncologists could choose. This year alone, 16 new measures were introduced. The measures are reassessed every six months to make sure they are effective and relevant.
Although there were many questions and concerns when ASCO first rolled out the quality program, McNiff says the aggregate results have been very helpful to members. ASCO is considering a certification program for practices that reach certain performance thresholds based on the indicators.
One way to maximize quality measures is to track ones that can also do double or triple duty for certification, credentialing, and other practical purposes, says Dr. Ferris, who presented on the efforts at Massachusetts General to develop and track quality indicators.
“We have at least two quantitative measures on every doctor at Mass General,” he says. He calls the quality measure development at the hospital “grassroots” and says that another good place to start for data management is with “low-hanging fruit,” such as data from notes in the electronic medical record.
For more information about the ACR Rheumatology Clinical Registry or to participate in the limited launch phase beginning in January, contact Amy S. Miller, ACR senior director of research, training, and quality, at [email protected]. For more information on the 2008 ACR Quality Stakeholders Summit or previous years’ summits, go to www.rheumatology.org/practice/qmc/collaboration.asp.
Vanessa Caceres is a medical writer and editor based in Virginia.
References
- Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). To err is human: Building a safer health system. Washington, D.C.: National Academy Press, 1999.
- Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, D.C.: National Academy Press, 2001.
