Background/Purpose: Population management (PM) is required for reducing the burdens of chronic diseases, including RA. PM depends on standardizing disease activity assessment (DAA) and coordinating care for the entire disease population, as well as for individuals within this context. Our purpose is to implement PM for RA within rheumatology practices by optimizing DAA to define controlled, low, moderate, and high disease activity cohorts; to focus resources on those patients with the highest needs; and to document our delivery of care and outcomes.

Methods: The Rheumatoid Arthritis Practice Performance (RAPP) Project is a rapidly growing voluntary collaboration of U.S. clinician rheumatologists (current N = 94) who manage more than 50,000 RA patients in total, based on ICD-9 diagnoses. Patients are being enrolled in an analytic RA disease population registry from practice billing records, and RAPP physicians are reporting their preferred disease activity measures, including CDAI, RAPID3, DAS28, SDAI, Physician Global Assessment, and/or a multi biomarker disease activity score. Monthly Population Reports are provided that include 1) patients registered (N) and % ever assessed, 2) % with controlled-low DAA within 7 months, 3) % with moderate-high DAA within 4 months, and 4) %’s with controlled, low, moderate, and high disease activity. Working lists are also provided of patients lacking timely DAA (Report numbers 1, 2, and 3), and those with high disease activity (number 4).  Practices are managing their DAA care gaps and high disease activity cohorts, and implementing these population management processes through clinical process improvement projects.

Results: Aggregated data from the baseline Population Reports for the first 26 fully enrolled registries are included in this abstract using multi-biomarker assay results. Other encounter-based disease activity measures are being added currently. The total patients enrolled  = 16,979 (Median = 594/physician). At least one DAA is documented for 58% of the total (Median/physician = 69%).  Forty-seven % of the controlled-low disease activity cohort has been assessed within 7 months, as has 29% of the moderate-high disease activity cohort within 4 months. The population disease activity distribution includes 21% with controlled-low, 39% with moderate, and 40% with high RA disease activity.

Conclusion: 1. These PM capabilities identify care gaps in DAA and disease control that were not identified previously. 2. Timely DAA and tracking of population measures are known to support improved care and disease activity outcomes.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/population-management-of-rheumatoid-arthritis-ra-in-rheumatology-practices-a-quality-improvement-project/