Quality Metrics in the Rheumatology Clinic
For instance, if we applied this to RA, we could try and understand this concept more easily. How do we know that our expensive new therapies are actually improving health outcomes in RA? To determine “cost,” we must determine the expense of the entire spectrum of care for the RA patient, from office visits to medications to hospitalizations, and determine the aggregate cost per patient. To determine the value of this care, we would need to measure predefined valid outcomes of care such as disease activity score, radiographic progression, functional status score, quality of life, etc. By acknowledging cost and outcomes, we can then compare the value of the delivered care. One can imagine that, to improve the value of care (the equation of outcomes/cost), we will have to improve efficiency by eventually redesigning our care delivery system to be patient centered to optimize efficiency. This may also include expanded use of technology to track disease activity and functional status in real time, substitute frequent office visits with proactive telephone outreach to patients who are doing well, employ physician extenders, and even schedule comprehensive multidisciplinary visits for patients on one day at one location. Ultimately, we would be able to understand if the changes we made to the entire system of delivering care to RA patients actually resulted in an improvement in value.
As rheumatologists, it may be easiest for us to focus on our treatment of patients with RA, since the quality of RA care has been the best studied of our rheumatic diseases.5 There is currently a first-generation set of RA quality measures that are used by the Centers for Medicare and Medicaid Services (CMS) for the Physician Quality Reporting System (PQRS). These include the documentation of disease activity, functional status, disease prognosis, tuberculosis testing prior to biologic initiation, glucocorticoid management plans, and the use of disease-modifying antirheumatic drug (DMARD) therapy. Physicians can submit data on their patients to CMS through PQRS in order to qualify for the bonus payment offered for reporting on quality measures. Does meeting this set of RA quality metrics confirm that quality care is being provided? Does the corollary hold true? Does failing to achieve these measures indicate poor care delivery? The answers to these questions are at the core of the debate about defining quality care.
Can we define the optimal quality metrics that are worth measuring? Not easily. Developing quality metrics that are clinically meaningful and improving performance through quality improvement activities takes both time and a shift in culture. For example, in our institution we were interested in seeing how often our clinic patients who were treated with immunosuppressive therapies were up to date with appropriate vaccinations. In preliminary studies, we observed that, in the majority of patients, we failed to provide vaccinations for pneumococcal disease or influenza—our initial rates of pneumococcal vaccination were below 50%, a somewhat surprisingly low number for a large, referral academic center.
