Background/Purpose: Current quality measures are diagnosis driven and focus on management.  For rheumatoid arthritis (RA), the Physician Quality Reporting System requires that a disease modifying anti-rheumatic drug (DMARD) therapy be prescribed.  Quality measures do not account for incorrect diagnoses.  Diagnostic error can stem from a physician or from a patient report of a medical history.  Prior studies have shown a discrepancy between patient report and physician diagnosis.  One study reported diabetes – a well defined disease – had no variance, while arthritis – a less clearly defined disease – had a 15% variance, with patients over reporting the disease.  Our objective is to determine the accuracy of RA diagnosis in our institution’s primary care offices and to evaluate if quality measures are met.

Methods: Adult patients with the International Classification of Diseases, Ninth Revision (ICD-9) code for Rheumatoid Arthritis (714.0) were searched from April 2011 to April 2013 using our institution’s primary care electronic medical record.  The medication list was reviewed for the presence of a DMARD.  The paper chart of patients seen in our institution’s rheumatology clinic was reviewed for a more accurate diagnostic code.   

Results: 246 patients were identified by ICD-9 code using the primary care electronic medical record; 172 were used for evaluation.  The average age of the patient population was 60.4 with a standard deviation of 12.7.  88.4% (152) were female.  The rate of incorrect ICD-9 coding by primary care physicians was 24-38% [CI of 95%].  The top 5 rheumatologist established diagnoses in these patients were osteoarthritis (20), other inflammatory arthritis (10), undifferentiated connective tissue disease (8), osteoporosis/osteopenia (5), and systemic lupus erythematosus (5).   In patients with rheumatologist confirmed RA, 12-26% [CI of 95%] did not have a DMARD in the primary care medication list.

Conclusion: The high incidence of primary care physicians erroneously utilizing the 714.0 ICD-9 code in our institution can be attributed to inaccurate reporting of the disease by the patient and its usage to rule out the disease.  In 48 cases, a patient reported to their primary care physician that they suffered from rheumatoid arthritis when in fact they had another diagnosis.  These patients with inaccurate ICD-9 codes will be inappropriately categorized as receiving poor levels of care by not meeting RA quality measures.  In patients with true disease, a lower percentage is noted to not meet the quality measure of DMARD treatment.  Interestingly, it was observed that injectible medications were not documented in the primary care medication list.  This could be due to the fact that patients often bring physical bottles for medication reconciliation and not the injectables.  Taking this into consideration, the percentage of RA patients not meeting quality measures is likely considerably lower.  In conclusion, since quality measures do not address the issue of inaccurate diagnosis, its emphasis on management and its potentially associated penalties should be reevaluated.  Further studies are needed to determine if patients with inaccurate coding are subjected to unnecessary treatment or testing.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/accuracy-of-international-classification-of-diseases-ninth-revision-coding-for-rheumatoid-arthritis-in-the-primary-care-setting/