Completed Projects Clinical Care
A Systems Approach to Improving Arthritis Clinical Care
The current health care delivery system, developed when acute illnesses were the most prominent health problems, is not well suited to meet the needs of individuals with chronic diseases such as arthritis. Systematic changes in health care delivery are required to meet the challenges of chronic disease management. The ultimate purpose of this contract was to pilot test a systems approach for improving the quality of arthritis clinical care. To support this systems approach, it was necessary to develop an algorithm that could be used to identify people with arthritis from automated health plan data systems, and to develop a method health organizations could use to estimate the size of their “arthritis problem”. The contract consisted of three components:
- Develop a patient algorithm to identify within administrative data systems individuals with arthritis and the subset of individuals appropriate to receive standardized care.
- Identify methods to define arthritis costs by estimating service use; such as, physician visits, hospitalizations, radiology, pharmaceuticals, and other related costs.
- Organize and facilitate a structured arthritis clinical care quality improvement initiative in partnership with one or two CDC-funded core arthritis programs in state health departments.
Objective 1: Case finding method for populating clinical management registries
- The automated data case-finding algorithm (defined as two ICD-9 codes recorded in the administrative data system) worked well to identify persons with a diagnosis of rheumatoid arthritis (as identified in the paper medical record). The same algorithm worked reasonably well for osteoarthritis and gout, and did not work well for fibromyalgia. More complex algorithms using arthritis-related laboratory test results and medication records did not substantially improve case finding via automated data systems.
- Rheumatoid arthritis is easily identified using ICD-9 data and can be readily used to populate population-based clinical management registries. Persons with a diagnosis of gout and osteoarthritis can be identified using automated data but a significant proportion of individuals will be missed and 18-22% will not actually have the condition. Fibromyalgia is poorly identified using automated data.
Objective 2: Defining arthritis-related costs by estimated service use from MCO records
- Organization-specific methods to make cost estimations from service use is challenging.
Objective 3: Pilot testing a systems approach to clinical quality improvement
- 67% of the professionals participating in the Improving Arthritis Clinical Care Collaborative I reported that they changed the way they treated patients with OA. The reported using tools such as planned or group visits, proactive follow-up, referrals to exercise or education programs, and routine assessment of pain and disability.
- Organizational challenges to quality improvement in arthritis included time constraints and competing demands, staff turn-over, lack of support from senior leadership, and lack of physician enthusiasm.
- Arthritis-specific challenges to quality improvement efforts included absence of clear clinical indicators of improvement (“there is no hemoglobin A1C for arthritis”), the subjective nature of pain and disability, and difficulty engaging patients who perceived other health problems as more pressing.
- Professionals participating in Collaborative II, which focused specifically on self management of osteoarthritis among patients with symptomatic OA, made similar changes in their practice and did not experience difficulties engaging OA patients with limitations to participate in the improvement efforts; in contrast, patients were “delighted’ that their OA was being seriously addressed.
List any the abstracts, publications, presentations:
Manuscript in preparation
Ed Wagner, MD, MPH
MacColl Institute for Health Care Innovation
Group Health Cooperative of Puget Sound
1730 Minor Ave, suite 1290
Seattle WA 98101
CDC Arthritis Program Contact: Teresa J. Brady, PhD
Last updated: September 2006