What Quality Improvement Means To Me | Rheumatoid Arthritis

In rheumatology, we are challenged with the formidable task of simultaneously improving quality, enhancing equity, and ensuring value in the care we provide for our patients. One of the ways we can do this is by being involved in research to help establish quality measures and outcome goals.

In 2015, the Physicians Quality Reporting System includes 254 quality measures across a range of medical specialty areas that touch on a variety of aspects of patient care. The six PQRS measures that are most specific to rheumatology are mentioned in the core article within this newsletter. While these measures all meet National Quality Standards (NQS) for effective clinical care, it is important to note that they are process-based and do not touch on patient outcomes.1

In the last 10 years, a number of researchers have designed user-friendly tools for use in research and clinical settings. Some of these tools reflect the significant gains we have made with our patient populations. For instance, drug research used to focus on improvements in ACR scores of only 20%. Now, 40% and 60% ACR improvement is a typical goal.

In addition, there are a number of validated quantitative tools at our disposal, including things like the MHAQ, CDAI, SDAI and Treat to Target guidelines that give us objective data by which to measure effective or ineffective patient care.2 While care of the RA patient is multidimensional and cannot be captured by one simple numeric outcome rating alone, these tools are at least starting points on the path toward quality improvement. While it has taken time even for some of these simpler tools to gain a foothold in rheumatology, now that there are financial incentives to use them, they are slowly becoming more commonplace in practice.

The question then is how do we move beyond these starting points and begin to define outcome-based quality measures in a chronic and complex disease such as RA? There are so many variables that need to be considered—including things like disease chronicity, treatment adherence, comorbidities, and access to care—that it seems a Herculean task to design a reliable outcomes tool.

Perhaps we need to include a variety of facets, such as radiographic stability and lack of progression (Sharp score), improvement of functional status, and reduction of DAS28 values. These are each certainly outcome-based dimensions, but none of them can stand alone as a measure of RA quality care.

Of course, some may argue that our primary goal in the treatment of RA should be to provide value: the health care outcomes achieved per dollar spent.3 If we diagnose RA earlier and treat it more aggressively with a combination of nonbiologic and biologic DMARDs, would it reduce the overall cost of patient care and improve overall patient outcomes? It is these questions that researchers are continuing to explore.

As rheumatology nurses, we must know and understand that PQRS, along with other measurement tools that we use to maximize payment and reimbursement rates, is important, but it does not truly represent an outcome-based improvement in quality patient care. Future RA quality measures must strive to reach this level and provide multidimensional components that can be easily integrated into daily practice. It is not an easy task. Electronic health records will help, but with the variety of systems in place and the amount of data that would need to be captured, moving quality goals in RA to an outcome-based level is going to require time and patience.

Jacqueline Fritz, RN, MSN, CNS, is owner and Coordinator of Education at the Medical Advancement Center in Cypress, CA, where she teaches RN/BSN programs at various facilities. She is also a Critical Care Clinical Nurse Consultant to many acute care facilities in the California area, such as Cigna, Arcadia Methodist, and Doctor’s Hospital of Lakewood.


  1. Centers for Medicare and Medicaid Services. 2015 Physician Quality Reporting System (PQRS) Measures Groups Specifications Manual. December 2014. Available at: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html.
  2. Smolen JS, Aletaha D, Bijlsma JW, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69(4):631-7.
  3. Desai SP, Solomon DH. A new paradigm of quality of care in rheumatoid arthritis: how our new therapeutics have changed the game. Arthritis Res Ther. 2013;15(5):121.