Background/Purpose:

The American College of Rheumatology (ACR) has endorsed a set of quality measurements for patients with rheumatoid arthritis (RA).  Our patient population was at two city hospitals which serve a large underserved population. This study is aimed to use these ACR quality measurements to assess the quality of care of RA patients in this population.

Methods:

This is a retrospective study conducted by chart review of patients with an ICD-9 or ICD-10 diagnosis code of RA that visited rheumatology clinic of two public hospitals in an underserved area between July 1st, 2015-July 1st, 2016.  All patients met ACR criteria for RA. We measured five ACR endorsed quality measurements (see Table 1) and compared between patients of different socioeconomic status (SES) and different provider type (trainees and attendings).

Results:

240 patients were seen in rheumatology clinic of the two public hospitals during the targeted time period, 89% of whom were of low SES defined as having Medicare/Medicaid or no insurance. Almost all patients were on DMARD (95.8%) during the index clinic visit and 35% were on biological DMARD.  The majority of the patients (7/11) not on DMARD were of low SES and were not on DMARD due to documented non-compliance and poor follow-up. All patients (83/84) with increased disease activity had changes in regimen except for one who refused changes. Among the 28 patients who were started on biological DMARD during the targeted year, 25% (7/28) had no tuberculosis (TB) screening documented within the prior 12 months (3 had TB screening more than 12 months prior, 2 were documented after initiation of biological DMARD and 2 had no documentation).  Less than half of the patients (43%) had Clinical Disease Activity Index (CDAI) documented in >=50% of the clinic encounters. Attendings had a slightly better percentage of CDAI documentation than trainees (49% vs 40%) but the difference was not statistically significant (chi-square test, p=0.206). Only 7% of patients were on prednisone > 10mg daily for more than 3 months and most of them (10/13) had a documented glucocorticoid taper plan.

Conclusion:

Providing high quality of care to patients with rheumatoid arthritis in an underserved area is challenging. Our providers did a good job of initiating DMARD, escalating treatment in the face of high disease activity and decreasing high prednisone doses.  In these areas, the main limitation was low SES with medication non-compliance.  Areas for improvement are reaching 100% screening for TB prior to starting biologics and to achieve higher disease activity documentation rate. Based upon this study, a prospective intervention will be started in the clinics to improve TB screening and documentation of disease activity as an ongoing divisional QI project.

Table 1: ACR Endorsed Quality Measurement