Background/Purpose:

Current
recommendations for optimal rheumatoid arthritis (RA) management include
routine assessment of disease activity and adjustment of medication to achieve
remission or low disease activity. There are limited data describing
implementation strategies for this potentially burdensome process in a
real-world clinic setting. Our goal was to increase the use of disease activity
measures, specifically, the Clinical Disease Activity Index (CDAI) for RA patients
at an academic VA medical center rheumatology clinic using Plan-Do-Study-Act
(PDSA) cycles and introduction of a simple paper form.

Methods :

Patients
were diagnosed with RA by a rheumatologist. In PDSA cycle 1, a paper-based form
was distributed to providers and brief one-on-one educational discussions with
incoming fellows were held. The form included a patient global activity of
disease visual analogue scale (VAS, 0-10cm), a physician global VAS and a 28-joint
count homunculus for counting tender/swollen joints. The form also included instructions
for calculation and interpretation of the CDAI. Providers were instructed to
enter the total CDAI score into their clinical note. PDSA cycle 2 included two provider
education talks on disease activity measurement including rationale, identification
of RA patients prior to their clinic visit by investigators, inclusion of
medical assistants to distribute paper forms to pre-identified patients, and
separation of the form into two pages – one for the patient global (was
changed from VAS to numerical in cycle 2) and one for the provider components.  We generated a run chart to evaluate the
effect of each PDSA cycle on the percent of RA visits with the CDAI recorded.

Results :

Nine
rheumatology fellows, 1 nurse practitioner and 5 attending physicians
participated in this quality improvement project. 107 RA patients were seen at
the clinic during the study period, June 2014 through March 2015. During the 4-week
pre-intervention period, there were 29 RA patient visits and 24% (n=7) had a documented
CDAI. PDSA cycle 1 lasted 8 weeks with 59 visits and 44% of patients (n = 26) had
a CDAI documented. Cycle 2 lasted 27 weeks with 182 visits and 85% of patients
(n = 155) had a CDAI documented.

Conclusion :

We
successfully increased CDAI use in an academic rheumatology clinic setting using
a simple paper form coupled with brief provider education. The majority of
providers were rheumatology fellows, indicating that providers can learn this skill
early in their training. Our approach may be informative for other clinical
settings, especially for

those without
an electronic medical record or those that are unable to modify their electronic
medical record to incorporate disease activity measures.