CRA Guidelines for the Management of Rheumatoid Arthritis- Update

May 25, 2013

Pooneh Akhavan, MD

1- Describe the CRA's multi-faceted approach to disseminate the RA recommendations

2- Understand the process of moving from RA guidelines to RA Quality Indicators

2

Learning Objectives

• CRA recommendations were supported by the CIHR and matched funds from the CRA

Disclosures

CRA Recommendations for RA ManagementJ Rheum 2012

Part 1: Treatment – 26 recommendations

• RA management strategies (6)• Glucocorticoids and traditional DMARDs (8)• Biologic DMARDs (12)

Part 2: RA drug safety – 13 recommendations

•Perioperative management (2)•Screening for LTBI prior to biologic therapy (4)•Optimal vaccination practices (3)•Treatment of RA patients with a history of malignancy (4)

CRA Recommendations for RA

1. Yes, read Part I: Treatment2. Yes, read Part II: Safety3. Yes, read both parts I and II4. No

Have you read the recommendations?

CRA Annual Meeting 2013- Ottawa

1 2 3 4

12%

43%44%

1%

• Dissemination activities• Moving towards the Quality Indicators

Presentation Outline

Dissemination

Overview Dissemination Activities

Completed

1. Publications (open access J Rheum / CRA website)

2. Presentations (Local, regional, national international)

3. Additional tools for download (CRA website)

4. CRA guideline self-evaluation survey followed by CRAJ question and answer series (Summer 2013)

In progress

1. MDbriefcase eRecommendation program (CME accredited)

2. EMR integration

In future

Multi-disciplinary RA guideline dissemination workshop September 2013

1. Dissemination Activities-Completed

Download RA

guideline documents

Download RA

algorithms &

slide decks

http://rheum.ca/en/publications/cra_ra_guidelines

Dissemination Activities-Completed

2. Presentations at rheumatology meetings:• International: ACR, EULAR• National: CRA, PANLAR• Regional meetings: WAR, ORA, SOAR,

Laurentian• Various local meetings

3. Slide decks as self-teaching tools and/or for presentations at local rounds and other educational activities (www.rheum.ca/en/publications/cra_ra_guidelines)

Dissemination Activities- Completed

4. CRA self-evaluation survey:

- 24 questions

- CRA membership

- April-May 2013

- 188 of 432 responded

- CRAJ series (to start this Summer)

1. MDbriefcase eRommendation program (will be CME accredited)

Dissemination Activities- In Progress

TREATMENT ASPECTS

SAFETY ASPECTS

Dissemination Activities- In Progress

2. Ongoing discussions with eHealth Ontario- EMR Integration of selected key recommendations to measure performance

Dissemination Activities- In Future

• CIHR meeting grant approved

• Objectives:• a) Discuss barriers and local adaptation issues from

knowledge users (clinicians, therapists, pharmacists, nurses and patients)

• b) Create a plan for targeted messages for each knowledge user group

• c) Start the process of identifying the Quality Indicators from the guidelines

Interdisciplinary Dissemination and Local Adaptation

Workshop (RA Guidelines)

September 2013

Overview Dissemination Activities

Completed

1. Publications (open access J Rheum / CRA website)

2. Presentations (Local, regional, national international)

3. Additional tools for download (CRA website)

4. CRA guideline self-evaluation survey followed by CRAJ question and answer series (Summer 2013)

In progress

1. MDbriefcase eRecommendation program (CME accredited)

2. EMR integration

In future

Multi-disciplinary RA guideline dissemination workshop September 2013

• Dissemination activities• Moving towards the Quality Indicators

Presentation Outline

Development of Canadian Quality of Care Indicators for RA

Developing QIs

Define the optimal standard of

care

Define the minimally acceptable standard of care

Quality Indicators

Clinical Practice Guidelines

Definitions

Quality Measure

• Measures the performance • Has detailed specifications (numerator/denominator)

Number of eligible patients receiving a process of care (×100)Number of patients eligible for a process of careExample: “the percentage of patients age 18 and older who were prescribed, dispensed, or administered at least one ambulatory prescription for a DMARD during the 12-month reporting period”

Another Example: TB screening

Numerator• Patients with a TB screening within six months prior to

receiving a first course of a biologic DMARD

Denominator• Patients 18 years with RA and receiving a first

course of a biologic DMARDDenominator Exclusions• Medical reason for not screening for TB

– Patient positive for TB and documentation of past treatment

– Patient who has recently completed a course of anti-TB therapy

Evolution of Quality of RA Care

RHEUMATOID ARTHRITIS GUIDELINES

2000 2002 2004 2006 2008 2010 2012

Evolution of Quality of RA Care

RHEUMATOID ARTHRITIS GUIDELINES

2000 2002 2004 2006 2008 2010 2012

2006 2008 2010 2012

RHEUMATOID ARTHRITIS QUALITY MEASUREMENT & IMPROVEMENT

From RA Guidelines to QIsACR 2012 RA QIs Canadian QIs- In progress

To develop evidence- and consensus-based quality indicators for the care of Canadian adults living with RA using current CRA guidelines

1. Assessment of Disease Activity

2. Assessment of Functional Status

3. TB testing4. Treatment with DMARDs5. Administration of influenza

vaccine6. Administration of

pneumococcal vaccine7. CBC, Cr and LFT check

For any queries/ comments about CRA recommendations for RA, please

contactraguidelines@rheum.ca

Acknowledgment

Dr. Pooneh AkhavanDr. Vivian BykerkDr. Claire Bombardier Mrs. Anne DooleyDr. Paul Haraoui Dr. Glen Hazlewood Dr. Majed KhraishDr. Sharon LeClercq Mr. Jean LégaréDr. Diane Mosher Dr. James Pencharz Dr. Janet PopeMs. Orit SchieirDr. John ThomsonDr. Carter ThorneDr. Michel Zummer

RA Guidelines Working Group

CRA On-line SurveyCRA On-line Survey

Dr. Sanjay Dixit