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Three Quality Improvement Initiatives Improved Performance of Rheumatoid Arthritis Disease Activity Measures in Electronic Health Records: Results from an Interrupted Time Series Study

Author

Gandrup J1, Li J1, Izadi Z2, Gianfrancesco M1, Ellingsen T3, Yazdany J1, Schmajuk G4. Arthritis Care Res (Hoboken). 2019 Feb 11. doi: 10.1002/acr.23848. [Epub ahead of print]

Author Information

1 Division of Rheumatology, University of California, San Francisco, San Francisco, CA.

2 Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA.

3 Department of Rheumatology, Odense University Hospital, Odense, Denmark.

4 Division of Rheumatology, UCSF and the Veterans Affairs Medical Center - San Francisco, San Francisco, CA.

Abstract

OBJECTIVE: 

Applying treat to target strategies in the care of patients with rheumatoid arthritis (RA) is critical for improving outcomes, yet electronic health records (EHRs) have few features to facilitate this strategy. We evaluated the effect of three health-IT initiatives on performance of RA disease activity measures and outcomes in an academic rheumatology clinic.

METHODS: 

We implemented three initiatives designed to facilitate performance of the Clinical Disease Activity Index (CDAI): an EHR flowsheet to input scores, peer performance reports, and an EHR SmartForm including a CDAI calculator. We performed an interrupted time-series trial to assess effects on the proportion of RA visits with a documented CDAI. Mean CDAI scores before and after the last initiative were compared using t-tests. Additionally, we measured physician satisfaction with the initiatives.

RESULTS: 

We included data from 995 patients with 8,040 encounters between 2012 and 2017. Over this period, electronic capture of CDAI increased from 0% to 64%. Performance remained stable after peer reporting and the SmartForm were introduced. We observed no meaningful changes in disease activity levels. However, physician satisfaction increased after SmartForm implementation.

CONCLUSION: 

Modifications to the EHR, provider culture, and clinical workflows effectively improved capture of RA disease activity scores and physician satisfaction, but parallel gains in disease activity levels were missing. This study illustrates how a series of health-IT initiatives can evolve to enable sustained changes in practice. Yet, capture of RA outcomes alone may not be sufficient to improve levels of disease activity without a comprehensive treat-to-target program.