Original Research – Abstract

Tailoring CME with Chart Audits Linked to Individual Physician Performance to Improve Rheumatoid Arthritis Quality Measures

TAMAR SAPIR, PHD; ERICA RUSIE, PHARMD; JEFFREY D. CARTER, PHD; LAURENCE GREENE, PHD; KATHLEEN MOREO, RN-BC, BSN, BHSA, CCM, CM, CDMS Key Words: quality improvement/Six Sigma/TQM, quality measures, chart audit, continuing medical education, audit and feedback education, rheumatoid arthritis

Introduction In efforts to improve the quality of care for patients with rheumatoid arthritis (RA), leaders in the US rheumatology community have developed evidence-based and consensus quality measures.1,2 These measures have been adopted by the Centers for Medicare & Medicaid Services (CMS) for its Physician Quality Reporting System (PQRS). In recent years, marked gaps and variability have been reported in rheumatologists’ adherence to RA quality measures.1–4 Experts in the field of quality improvement (QI) have recognized the potential for continuing education programs to enhance health care practices that are assessed through quality measures.5 Preliminary studies have demonstrated this potential in areas including diabetes, venous thromboembolism, radiation oncology, and inflammatory bowel disease.6–9 To date, however, no published study has reported on the impact of continuing education on adherence to quality measures for RA. We developed a multicomponent, interprofessional education program to support rheumatologists and managed care professionals in aligning their practices with quality measures, evidence-based guidelines, and National Quality StratDisclosure: The authors report that this project was supported by an educational grant from Genentech. Dr. Sapir: Chief Scientific Officer, PRIME Education, Inc; Dr. Rusie: Advanced Clinical Writer, PRIME Education, Inc; Dr. Carter: Population Health and Research Manager, PRIME Education, Inc; Dr. Greene: Scientific Education Manager, PRIME Education, Inc; Ms. Moreo: President and CEO, PRIME Education, Inc. Correspondence: Laurence Greene, PRIME Education, Inc, 8201 West McNab Road, Tamarac, FL 33321; e-mail: [email protected]. © 2015 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on Continuing Medical Education, Association for Hospital Medical Education • Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/chp.21285

egy (NQS) priorities. Here, we report one component of this program, a pragmatic study involving chart audits to assess the impact of QI-focused education on rheumatologists’ adherence to PQRS measures for RA. Methods The methods were approved by an independent institutional review board (Sterling IRB, Atlanta, GA). Twenty community-based rheumatologists were recruited to participate in baseline chart audits, educational activities, and posteducation chart audits. Participants treated an average of 41 RA patients weekly and represented states in different regions of the country. At baseline, we sought to review 160 charts of RA patients who had at least one visit with their participating rheumatologist from December 1, 2012, to November 30, 2013. An oversample of 12 charts was requested from each practice with the goal of obtaining an average of 8 charts per rheumatologist. At baseline, a trained medical chart reviewer abstracted the charts for the rheumatologists’ documented performance on the 6 RA quality measures included in the 2013 PQRS program.10 After the baseline audits, the rheumatologists participated in a CME Web-based, private audit feedback session and a CME small-group interactive webinar, each lasting 45 minutes. In the audit feedback session, a doctoral-trained pharmacist with expertise in medical chart review presented the participant’s baseline rates of adherence to the quality measures and compared them with the deidentified, pooled rates of the other 19 rheumatologists. The ensuing webinar was limited to 5 participants and was presented on 4 occasions by an expert rheumatologist, who guided discussion and feedback on strategies for improving adherence to the quality measures. Participation in the audit feedback session and small-group webinar was confirmed by roll call. The 20 rheumatologists also received, and were asked to read or

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CME and Chart Audits Linked to Performance

view, a 10-page monograph presenting the evidence-based rationale for the measures and a 12-page CME monograph and 30-minute video program addressing interprofessional approaches to high-quality RA care among rheumatologists and managed care professionals. Nonaccredited tools to improve measurement documentation were also provided in an RA toolkit. Six months after the educational activities, charts were again randomly selected and abstracted for each of the 20 rheumatologists; the abstraction period was 6 months. We conducted chi-square tests to analyze baseline and posteducation differences in the frequencies of patient charts with documented performance of each measure. P values less than .05 were considered significant. Results The analysis included 160 baseline charts (mean = 8 per physician; range = 4–9) and 160 posteducation charts (mean = 8 per physician; range = 4–9). Rates of adherence were significantly higher in posteducation versus baseline charts for 4 of the 6 PQRS measures: assessment and classification of disease activity (63% vs 40%, p < .001); assessment and classification of disease prognosis (54% vs 31%, p = .005); assessment of functional status (83% vs 74%, p = .011); and tuberculosis screening before biologic disease-modifying antirheumatic drug (DMARD) therapy (42% vs 18%, p < .001). Posteducation and baseline rates were not significantly different for prescription of DMARD therapy (97% vs 99%, p = .252). For the sixth PQRS measure, documentation of a glucocorticoid management plan, only 2 patients in the posteducation sample met the eligibility requirement of prolonged high-dose glucocorticoid therapy; thus, analysis was precluded. Discussion Our findings indicate that education on strategies for improving adherence to RA quality measures is associated with significant increases in rates of documented adherence to these measures among community-based rheumatologists. These improvements have the potential to positively affect patient outcomes. The measures for assessing and classifying disease activity and prognosis, and for assessing functional status, are especially important for guiding treatment decisions and monitoring outcomes.11,12 The measure for tuberculosis screening in patients initiating biologic therapy aligns with the NQS priority of promoting patient safety.13 This pragmatic study was not designed to determine the extent to which the different educational activities comprising the intervention influenced outcomes, so the important

question of which were the “active ingredients” remains unanswered. However, a large-scale meta-analysis has indicated that audit and feedback, a primary intervention in our study, is associated with small but meaningful improvements in clinical performance.14 To objectively assess the effects of different educational methods on physicians’ adherence to quality measures, new studies are needed with comparative effectiveness designs and control groups that do not participate in the targeted educational interventions. References 1. Saag KG, Yazdany J, Alexander C, et al. Defining quality of care in rheumatology: the American College of Rheumatology white paper on quality measurement. Arthritis Care Res (Hoboken). 2011;63(1):2–9. 2. Desai SP, Yazdany J. Quality measurement and improvement in rheumatology: rheumatoid arthritis as a case study. Arthritis Rheum. 2011;63(12):3649–3660. 3. Bombardier C, Mian S. Quality indicators in rheumatoid arthritis care: using measurement to promote quality improvement. Ann Rheum Dis. 2013;72(Suppl 2):ii128–131. 4. Schmajuk G, Trivedi AN, Solomon DH, et al. Receipt of diseasemodifying antirheumatic drugs among patients with rheumatoid arthritis in Medicare managed care plans. JAMA. 2011;305(5):480–486. 5. Shojania KG, Silver I, Levinson W. Continuing medical education and quality improvement: a match made in heaven? Ann Intern Med. 2012;156(4):305–308. 6. Peterson LE, Blackburn B, Phillips RL, Puffer JC. Improving quality of care for diabetes through a maintenance of certification activity: family physicians’ use of the chronic care model. J Contin Educ Health Prof. 2014;34(1):47–55. 7. Al-Hameed F, Al-Dorzi HM, Aboelnazer E. The effect of a continuing medical education program on venous thromboembolism prophylaxis utilization and mortality in a tertiary-care hospital. Thromb J. 2014;12:9. 8. Leong CN, Shakespeare TP, Mukherjee RK, et al. Efficacy of an integrated continuing medical education (CME) and quality improvement (QI) program on radiation oncologist (RO) clinical practice. Int J Radiat Oncol Biol Phys. 2006;66(5):1457–1460. 9. Greene L, Sapir T, Moreo K, Carter J, Higgins PD. Impact of quality improvement education on documented adherence to quality measures for adults with Crohn’s disease. Inflamm Bowel Dis. In press. 10. Centers for Medicare & Medicaid Services. 2013 Physician Quality Reporting System. Available at: http://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/PQRS/2013-PhysicianQuality-Reporting-System.html. Accessed December 12, 2014. 11. Anderson J, Caplan L, Yazdany J, et al. Rheumatoid arthritis disease activity measures: American College of Rheumatology recommendations for use in clinical practice. Arthritis Care Res (Hoboken). 2012;64(5):640–647. 12. Skapenko A, Prots I, Schulze-Koops H. Prognostic factors in rheumatoid arthritis in the era of biologic agents. Nat Rev Rheumatol. 2009;5(9):491–496. 13. Agency for Healthcare Research and Quality. The National Quality Strategy. Available at: http://www.ahrq.gov/workingforquality. Accessed December 12, 2014. 14. Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012;6:CD000259.

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Tailoring CME with chart audits linked to individual physician performance to improve rheumatoid arthritis quality measures.

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