Rheumatoid Arthritis: MacLean CH

Khanna D, Arnold EL, Pencharz JN, Grossman JM, Traina SB, Lal A, MacLean CH. · Division of Immunology, University of Cincinnati and VAMC, OH, USA. · Semin Arthritis Rheum. · Pubmed #16461068 No free full text.

Abstract: OBJECTIVE: To describe the scientific evidence that supports each of the explicit process measures in the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis. METHODS: For each of the 27 measures in the Arthritis Foundation's Quality Indicator set, a comprehensive literature review was performed for evidence that linked the process of care defined in the indicator with relevant clinical outcomes and to summarize practice guidelines relevant to the indicators. RESULTS: Over 7500 titles were identified and reviewed. For each of the indicators the scientific evidence to support or refute the quality indicator was summarized. We found direct evidence that supported a process-outcome link for 15 of the indicators, an indirect link for 7 of the indicators, and no evidence to support or refute a link for 5. The processes of care described in the indicators for which no supporting/refuting data were found have been assumed to be so essential to care that clinical trails assessing their importance have not, and probably never will be, performed. The process of care described in all but 2 of the indicators is recommended in 1 or more practice guidelines. CONCLUSION: There are sufficient scientific evidence and expert consensus to support the Arthritis Foundation's Quality Indicator Set for Rheumatoid Arthritis, which defines a minimal standard of care that can be used to assess health care quality for patients with rheumatoid arthritis.

Yazdany J, MacLean CH. · Division of Rheumatology, Department of Medicine, University of California-San Francisco, CA 94143, USA. · Curr Opin Rheumatol. · Pubmed #18349745 No free full text.

Abstract: PURPOSE OF REVIEW: To review the recent literature examining quality of care for several prevalent rheumatic conditions, including rheumatoid arthritis, osteoarthritis, gout and osteoporosis, and to summarize quality measurement and improvement initiatives relevant to rheumatology in the USA. RECENT FINDINGS: In recent years, research has identified a significant gap between ideal and actual clinical practice in the USA. Consistent with trends seen in the US healthcare system as a whole, research suggests deficits in healthcare quality for populations with rheumatic conditions. We review the growing literature on quality of care for rheumatoid arthritis, osteoarthritis, gout and glucocorticoid-induced osteoporosis. SUMMARY: Existing evidence suggests suboptimal healthcare quality for four common rheumatic conditions, a finding that parallels trends in the healthcare system as a whole.

MacLean CH. · University of California-Los Angeles Multipurpose Arthritis and Musculoskeletal Diseases Center, Los Angeles, California, USA. · Curr Opin Rheumatol. · Pubmed #11224733 No free full text.

Abstract: An understanding of the level of health care quality and the factors that affect it is necessary for providers and insurers to optimize health outcomes for patients and should be carefully considered when making decisions about resource allocation. Additionally, information about health care quality can be used by patients and others to inform decisions about the purchase of health care. Although much work has been done to characterize the quality of health care, little is known about the quality of care for the rheumatic diseases. This paper reviews what is known about health care quality for these diseases.

Sampsel SL, MacLean CH, Pawlson LG, Hudson Scholle S. · National Committee for Quality Assurance, Washington, DC 20036, USA. · Clin Exp Rheumatol. · Pubmed #18021503 No free full text.

Abstract: OBJECTIVE: Performance measurement at various levels of the health care system promotes improved processes that can result in the provision of more consistent and effective care. This chapter articulates the methodology and criteria utilized in measures development to ensure accountability and serve the information needs of physicians, health care systems, health plans and consumers, using arthritis and osteoporosis as example conditions. METHODS:Observational studies conducted to assess the validity and feasibility of performance measures focused on arthritis and osteoporosis. Clinical expert panels were convened to develop measure specifications based on guidelines and evidence supporting critical aspects of care. The aspects of care that were assessed included: DMARD utilization for patients with rheumatoid arthritis; appropriate gastrointestinal prophylaxis for patients utilizing NSAIDS; comprehensive osteoarthritis care; comprehensive symptom assessment and medical management of woman over 65 years who experienced a bone fracture. RESULTS:The implementation of performance measures for key aspects of arthritis and osteoporosis care is challenged by the availability of administrative data. However, potential for improvement is evident in each of the areas studied. CONCLUSION: The key challenge to the feasibility of arthritis performance measures is the lack of administrative data to identify the eligible population. Administrative data capture suffers as a result of under-coding and under-recognition of arthritis. Consensus around a single set of measures creates a powerful tool for focusing on key components of care as a basis for quality improvement and allows for a valid comparison of care within and across health care settings.

Kahn KL, MacLean CH, Liu H, Rubenstein LZ, Wong AL, Harker JO, Chen WP, Fitzpatrick DM, Bulpitt KJ, Traina SB, Mittman BS, Hahn BH, Paulus HE. · University of California at Los Angeles, Greater Los Angeles VA Healthcare System, Los Angeles, California 90095-1736, USA. · Med Care. · Pubmed #17279021 No free full text.

Abstract: BACKGROUND: Patients with rheumatoid arthritis (RA) provide an important opportunity for understanding care of patients with a serious chronic condition. OBJECTIVES: We sought to characterize the complexity of care for patients with RA, including metrics describing the patient, the disease, and use of the health care system across time and place. METHODS: We undertook a prospective cohort study of 568 community-dwelling patients with RA by using observational data from clinically detailed telephone interviews at baseline and 2 years later in addition to medical record abstraction. Health status, comorbidity, use of disease-modifying antirheumatic drugs, visits, providers, provider types, encounter settings, and the discontinuity between patients and providers were studied. RESULTS: Within a 12-month window, 568 patients had 8686 outpatient encounters with the health care system with a mean of 3.41 unique providers per patient associated with a mean of 5 primary care and 6 rheumatologist visits. Half did not see a primary care physician, and 20% did not see a rheumatologist during 6-month periods despite their use of potentially toxic drugs, a mean of 4 comorbidities and progressive RA. Over the course of 24 months, 29% of patients changed their primary care provider, and 15% changed their rheumatologist. Patients were moderately impaired with mean SF-12 physical component score 37 (SD, 9). CONCLUSION: Patients with RA have frequent encounters with multiple providers and also frequent discontinuity of care. Recognizing the complexity of the care of patients with a chronic disease across multiple dimensions provides an opportunity to better understand challenges and opportunities in delivering high quality care.

Kahn KL, MacLean CH, Liu H, Rubenstein LZ, Wong AL, Harker JO, Chen WP, Fitzpatrick DM, Bulpitt KJ, Traina SB, Mittman BS, Hahn BH, Paulus HE. · Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA 90095-1736, USA. · Arthritis Rheum. · Pubmed #17139665 links to  free full text

Abstract: OBJECTIVE: To construct quality measures with measurement validity and meaning for clinicians. METHODS: We conducted a prospective cohort study of rates of change in disease-modifying antirheumatic drug (DMARD) and/or systemic corticosteroid drug or dose for 568 patients with rheumatoid arthritis (RA) across 6,159 clinical encounters within 12 months to examine how changes in clinical specifications change adherence. RESULTS: Rates of DMARD change were sensitive to specifications regarding the intensity of disease activity (severe or moderate), duration of specified disease activity, and length of the observation period. Over 12 months, the proportions of 377 patients with severe disease activity observed for 1-month, 2-month, and 3-month time blocks who had a change in DMARD drug or dose were 36%, 57%, and 74%, respectively. Over 12 months, a change in DMARD drug or dose was observed for 44%, 50%, and 68% of 377 patients with severe disease within 3 months, 6 months, and 12 months, respectively, of the patient meeting criteria for severe disease activity. A change in DMARD drug or dose was observed for 21%, 23%, and 34% of 149 patients with moderate disease activity within 3, 6, and 12 months, respectively, of the patient meeting criteria for moderate disease activity. CONCLUSION: Rates of pharmacologic interventions for patients with moderate and severe RA disease activity vary substantially by intensity and duration of disease activity and by duration of period for observing change. Lack of precision in explicit process criteria could substantially mislead comparisons of quality of care across comparison groups.

Traina SB, MacLean CH, Park GS, Kahn KL. · Division of Rheumatology, Department of Medicine, The David Geffen School of Medicine, University of California at Los Angeles, CA 90095, USA. · J Clin Epidemiol. · Pubmed #15939228 No free full text.

Abstract: BACKGROUND: This study assessed the impact of follow-up reminder phone calls on response rates to a mailed consent form packet. METHODS: Patients with rheumatoid arthritis were invited to enroll in a study by signing and returning consent forms by mail. Patients not returning completed study consent forms were called and reminded to return the signed consent forms. RESULTS: Among 724 mailed consent form packets, 376 (52%) were returned without further follow-up. Follow-up reminder calls were made to 220 of the 348 patients who did not return signed consent forms. Among subjects contacted by phone, 67 (31% of those called) returned signed consent forms. CONCLUSION: Follow-up reminder phone calls raised the overall consent rate of 52 to 61%, suggesting that they can be an effective technique in increasing response rates.

MacLean CH, Mojica WA, Morton SC, Pencharz J, Hasenfeld Garland R, Tu W, Newberry SJ, Jungvig LK, Grossman J, Khanna P, Rhodes S, Shekelle P. · No affiliation provided · Evid Rep Technol Assess (Summ). · Pubmed #15133890 links to  free full text

This publication has no abstract.

MacLean CH, Saag KG, Solomon DH, Morton SC, Sampsel S, Klippel JH. · RAND Corporation, Santa Monica, California and University of California Los Angeles School of Medicine, USA. · Arthritis Rheum. · Pubmed #15077259 links to  free full text

Abstract: OBJECTIVE: To develop a comprehensive set of explicit process measures to assess the quality of health care for osteoarthritis, rheumatoid arthritis, and analgesics use. METHODS: Potential quality measures and a summary of existing data to support or refute the relationship between the processes of care proposed in the indicators and relevant clinical outcomes were developed through a comprehensive literature review. The proposed measures and literature summary were presented to a multidisciplinary panel of experts in arthritis and pain. Using a modification of the RAND/UCLA Appropriateness Method, the panel rated each proposed measure for its validity as a measure of health care quality. RESULTS: Among 66 proposed indicators, the expert panel rated 51 as valid measures of health care including 14 for osteoarthritis, 27 for rheumatoid arthritis, and 10 for analgesics use. CONCLUSIONS: Sufficient scientific evidence and expert consensus exist to support a comprehensive set of measures to assess the quality of heath care for osteoarthritis, rheumatoid arthritis, and analgesics use. These measures can be used to gain an understanding of the quality of care for patients with arthritis.

Griffiths RI, Bar-Din M, MacLean CH, Sullivan EM, Herbert RJ, Yelin EH. · Project HOPE Center for Health Affairs, 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133, USA. · Arthritis Care Res. · Pubmed #14635276 No free full text.

Abstract: OBJECTIVE: To identify costs among rheumatoid arthritis (RA) patients receiving alternative disease-modifying antirheumatic drug (DMARD) therapies. METHODS: Using managed care organization data, we identified members who (a) were prescribed any DMARD therapy for two consecutive months between July 1993 and February 1998, (b) were aged > or = 18 years, (c) had > or = 6 months of DMARD-free enrollment prior to the first DMARD, and (d) had a diagnosis of RA. RESULTS: The average age of the cohort (n = 571) was 51 years, and 70% were women. Mean duration of enrollment following initiation of DMARD therapy (observation period) was 19.5 months; 28.8% of patients switched DMARD regimens. The average monthly cost of care was $853, of which $294 (34%) was for RA-coded medical services. Monthly RA-coded costs varied by DMARD: hydroxychloroquine $227 (n = 252), methotrexate $340 (n = 185); sulfasalazine $233 (n = 49), and other mono/combination therapy $425 (n = 85) (P = 0.001). CONCLUSION: Costs of RA-coded care in patients receiving DMARDs are low and vary by DMARD.

MacLean CH, Louie R, Leake B, McCaffrey DF, Paulus HE, Brook RH, Shekelle PG. · UCLA Division of Rheumatology, 1000 Veteran Ave, Room 32-59, Los Angeles, CA 90095-1670, USA. · JAMA. · Pubmed #10944644 links to  free full text

Abstract: CONTEXT: Patients with rheumatoid arthritis are at risk for substantial morbidity because of their arthritis and premature mortality due to comorbid diseases. However, little is known about the quality of the health care that these patients receive. OBJECTIVE: To assess the quality of the health care that rheumatoid arthritis patients receive for their arthritis, comorbid diseases, and health care maintenance and to determine the effect of patterns of specialty care on quality. DESIGN, SETTING, AND PARTICIPANTS: Historical cohort study of 1355 adult rheumatoid arthritis patients enrolled in the fee-for-service or discounted fee-for-service plans of a nationwide US insurance company. Patients were identified and followed up through administrative data between 1991 and 1995. MAIN OUTCOME MEASURES: Quality scores for arthritis, comorbid disease, and health care maintenance were developed from performance on explicit process measures that related to each of these domains and described the percentage of indicated health care processes performed within each domain during each person-year of the study. RESULTS: During 4598 person-years of follow-up, quality scores were 62% (95% confidence interval [CI], 61%-64%) for arthritis care, 52% (95% CI, 49%-55%) for comorbid disease care, and 42% (95% CI, 40%-43%) for health care maintenance. Across domains, care patterns including relevant specialists yielded performance scores 30% to 187% higher than those that did not (P<.001) and 45% to 67% of person-years were associated with patterns of care that did not include a relevant specialist. Presence of primary care without specialty care yielded health care maintenance scores that were 43% higher than those for patterns that included neither primary nor relevant specialty care (P<.001). CONCLUSIONS: In this population, health care quality appears to be suboptimal for arthritis, comorbid disease, and health care maintenance. Patterns of care that included relevant specialists were associated with substantially higher quality across all domains. Patterns that included generalists were associated with substantially higher quality health care maintenance than patterns that included neither a generalist nor a relevant specialist. The optimal roles of primary care physicians and specialists in the care of patients with complex conditions should be reassessed. JAMA. 2000;284:984-992