Application of Explicit Process of Care Measurement to Rheumatoid Arthritis: Moving from Evidence to Practice

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1 Arthritis & Rheumatism (Arthritis Care & Research) Vol. 55, No. 6, December 15, 2006, pp DOI /art , American College of Rheumatology ORIGINAL ARTICLE Application of Explicit Process of Care Measurement to Rheumatoid Arthritis: Moving from Evidence to Practice K. L. KAHN, 1 C. H. MACLEAN, 2 H. LIU, 3 L. Z. RUBENSTEIN, 4 A. L. WONG, 5 J. O. HARKER, 6 W. P. CHEN, 3 D. M. FITZPATRICK, 3 K. J. BULPITT, 7 S. B. TRAINA, 3 B. S. MITTMAN, 6 B. H. HAHN, 3 AND H. E. PAULUS 3 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 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. KEY WORDS. Rheumatoid arthritis; DMARDs; Quality of care. INTRODUCTION Explicit process measurement is used to assess whether patients receive services they need. The most rigorous means for establishing need is demonstration of improved outcomes among patients who receive a service as compared with those who do not. When available, the results of randomized controlled trials can be used to inform the construction of explicit process measures (1). But trials are often conducted for a select homogenous cohort of patients not representative of the patients who span the quality of care spectrum (2). Therefore, even when trials provide evidence regarding the efficacy of an intervention for one Supported by the NIH (grant 5 P60-AR-36834) and the University of California, Los Angeles Multipurpose Arthritis and Musculoskeletal Disease Center. Dr. MacLean is recipient of a Veterans Affairs Health Services Research and Development Career Development award. 1 K. L. Kahn, MD: University of California, Los Angeles, and RAND, Santa Monica, California; 2 C. H. MacLean, MD, PhD: University of California, Los Angeles, and Greater Los Angeles VA Healthcare System, Los Angeles, California; 3 H. Liu, PhD, W. P. Chen, MA, D. M. Fitzpatrick, RN, S. B. Traina, PhD, B. H. Hahn, MD, H. E. Paulus, MD: University of California, Los Angeles; 4 L. Z. Rubenstein, MD, MPH: RAND, Santa Monica, and Greater Los Angeles VA Healthcare System, Los Angeles, California; 5 A. L. Wong, MD: University of California, Los Angeles, Greater Los Angeles VA Healthcare System, Los Angeles, and Los Angeles County/Olive View/University of California, Los Angeles Medical Center, Sylmar, California; 6 J. O. Harker, PhD, B. S. Mittman, PhD: Greater Los Angeles VA Healthcare System, Los Angeles, California; 7 K. J. Bulpitt, MD: Kaiser Permanente West Los Angeles Medical Center, Los Angeles, California. Address correspondence to K. L. Kahn, MD, University of California at Los Angeles, David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research, 911 Broxton Plaza, Box , Los Angeles, CA kkahn@mednet.ucla.edu. Submitted for publication February 9, 2006; accepted in revised form March 29,

2 RA and Process of Care Measurement 885 cohort, data are often not available regarding the efficacy of the intervention for similar, but not identical cohorts or for cohorts quite distinct from those in trials. Given the limited number of clinical interventions that have undergone rigorous trials during the last decade, quality of care measures endorsed by national or professional expert panels have been used to supplement trial evidence (3). Regardless of whether evidence is derived from clinical trials or from professional consensus, the specification of evidence is only the first step in the construction of explicit process measures. The next steps in the construction of quality of care measures are the specification of the need for the intervention and the determination of whether the person who needs the intervention receives it. Not much has been published regarding the methodologic and policy challenges associated with definitions of need for and use of the intervention. This study examined the anatomy of a single explicit process measurement that is built on extensive clinical trials evidence (4 7), as well as recommendations from 2 consecutive professional organization guidelines (8,9). The analysis provides a model for the complexity of quality measures and provides a structure for understanding how the construction of the measure will influence adherence rates. PATIENTS AND METHODS Disease-modifying antirheumatic drugs (DMARDs; including anticytokine therapies) are considered critical for optimizing outcomes for patients with rheumatoid arthritis (RA) (10 12). Because the march toward joint destruction continues in patients with moderate, severe, or worsening disease activity, providers should monitor patients disease activity regularly (9) and initiate a new intervention if patients do not improve with the prior therapeutic intervention (8,9). The exact time for initiating a second intervention for patients with active disease is not precisely known. However, initiation of a second intervention within 3 6 months of the first intervention has been recommended (8,9,13). Field work. We recruited 568 patients with known RA from 3 distinct care settings, including managed care and other practice settings, to participate in a systematic evaluation of the care received by patients with RA. Patients were recruited from a large discounted fee-for-service plan associated with a major west coast insurance company, from 3 west coast medical groups, and from a consortium of mostly west coast rheumatologists who share a vision for studying clinical care and outcomes for patients with RA. These sites identified patients who had a newly abnormal rheumatoid factor ( 20 IU or 1:20 titer), multiple claims suggesting a diagnosis of RA, or a clinical diagnosis by a rheumatologist. Patients who met 1 of these case identification criteria were invited to participate in a screening survey that assessed patient self report of the standard criteria for a diagnosis of RA (14,15). Consenting patients who fulfilled our criteria for RA based on both case identification steps (14,16) were invited to participate in the baseline computer-assisted telephone interview (CATI) survey. At baseline and 2 years later, patients responded to health status questions that allowed the calculation of the Short Form 12 (SF-12) (17), Health Assessment Questionnaire (HAQ) disability index (18,19), and the mean RA Activity Score derived from the Rheumatoid Arthritis Disease Activity Index (RADAI) (20,21). The surveys also allowed patients to self report the names of all providers who fulfilled the roles of the current primary care provider, the current arthritis doctor, the prior arthritis doctor, the doctor who first told the patient of the diagnosis of RA, the doctor who first prescribed a DMARD for RA, another main doctor (other than a primary care or arthritis doctor, such as a gynecologist or cardiologist), and a nurse practitioner or physician s assistant. The medical record volumes of all providers who fulfilled these roles for consenting patients were accessed, photocopied in full, and abstracted at a centralized research site by trained nurse abstractors experienced in both clinical practice and quality measurement. Data were collected across both the inpatient and ambulatory setting, across multiple providers, and across multiple and variable time periods. Abstraction data were collected from 6,159 clinical encounters across 12 months, both at the level of the patient (once) and at the level of the patientvisit dyad, iteratively for each encounter (22). The abstraction period included the 12 months prior to the baseline CATI interview. Construction of an explicit process measure. Explicit process measures are constructed to evaluate whether patients who need a service receive the service. For example, an explicit measure pertinent to the use of DMARDs will define the patient s needs and specify whether or not the patient used the medication. Traditionally, explicit process measures have been conceptualized as follows: IF the patient has a need, THEN the patient should receive the intervention to address that need (23 27). Properly specified IF statements define data sources and periods that determine a need as well as any characteristics that might exclude a patient from the cohort requiring the intervention. For example, age, sex, patient preferences, comorbid conditions, or past responses to interventions might exclude patients from the eligible cohort. THEN statements define whether or not members of the IF cohort receive the intervention (expected to improve outcomes). Specifications include acceptable interventions, synonyms for the interventions, and periods during which the intervention must be delivered. Explicit quality measurement is typically presented as the proportion of patients eligible for the intervention (i.e., the number of patients who meet the IF statement) who receive the intervention within the specified period (i.e., the number of patients who meet the THEN statement). Specification of the cohort eligible for the process intervention (i.e., defining the IF statement). Standard rheumatologic teaching and guidelines currently recommend the use of a DMARD intervention for patients with moderate

3 886 Kahn et al or severe disease activity and/or for patients with worsening disease activity (8,9). Accordingly, we used such patients to define the cohort of patients who should benefit from a DMARD intervention. Disease activity may be based on patient report of health status (18,19) and/or evaluation by physical examination (28), radiographs (29), and/or serum markers (30). Although frequent serial health status reports from patients might provide data to estimate probabilities for outcomes dependent on use of an intervention, that methodology is not likely to be available in most quality measurement circumstances. One alternative method for understanding patients need for an intervention is based on detailed clinical review of every patient encounter as documented in the medical record. For the present analysis, we measured disease activity according to documentation of patient status in the medical record. For each clinical encounter documented in the medical record, the nurse abstractor recorded the presence or absence of each of the following: evidence for joint pain, swelling, synovitis, or worsening; the intensity of joint symptoms; provider documentation of patient and/or provider global assessment; and joint counts. We used medical record data to generate a disease activity score. Patients with medical record documentation for worsening joint pain, swelling, synovitis, and poor or worsening global status were categorized as having severe disease activity. Patients with medical record documentation for joint pain, swelling, or synovitis, but no evidence for worsening joints and no evidence for poor or worsened global status were categorized as having moderate disease activity. Patients with no such medical record evidence were categorized as having minimal disease activity. To evaluate the validity of this method of assessing disease activity using medical records, we studied the relationship between activity scores derived from medical records and patient self-report health status measures. We tested differences between groups using analysis of variance. Specification of the process intervention (i.e., defining the THEN statement). We analyzed patients use of a DMARD-related intervention, defined as the initiation of a new DMARD (including tumor necrosis factor [TNF ] inhibitors), and/or systemic corticosteroid medication or a change in the dose of any of these medications during specified for patients with mild, moderate, or severe disease activity. With explicit process measurement, these explicit rates of use define rates of adherence to process criteria and so form the basis for patient-level quality of care scores. Specifying the period during which the intervention must be delivered. Specification of the exact period during which the intervention must be met to fulfill adherence to the explicit process measure (i.e., criteria for meeting the THEN statement) is necessary to ensure consistent measurement across users. For this analysis, the criteria for meeting the THEN statement were defined by the period during which a DMARD (or systemic corticosteroid) intervention must be delivered for eligible patients. RESULTS Table 1. Patient cohort (n 568)* Patient characteristic Value Age, years Overall mean SD (2) (29) (57) (11) Female sex 442 (78) Race American Indian 2 (0.4) Asian or Pacific Islander 15 (3) White 471 (83) African American 15 (3) Multiracial and other 65 (11) Marital status Married 406 (71) Widowed 31 (5) Divorced or separated 77 (14) Never married 51 (9) Do not know, refused, or missing 3 (1) marital status * Values are the number (percentage) unless otherwise indicated. Patient characteristics. The study cohort included 568 patients with medical record confirmation of a diagnosis of RA from 1 of 3 types of practice settings: a fee-for-service plan (386 [68%] patients), medical groups (83 [15%] patients), and a consortium of mostly west coast rheumatologists who share a vision for studying clinical care and outcomes for patients with RA (99 [17%] patients). The mean SD age was years, with 2% of patients 30 years of age and 11% 65 years of age; 78% were women (Table 1). Disease duration varied: 2 years (11%), 2 5 years (25%), 5 10 years (29%), years (10%), and 15 years (26%). Nine percent had disability or extended sick leave. Patient report of DMARD data. Whereas 15% of the 568 patients did not receive a DMARD or TNF inhibitor during the 12 months prior to the baseline survey, 85% did receive a DMARD, including 28% who also received a TNF inhibitor. Four percent received a TNF biologic without a DMARD. Most (75%) of the patients who did not receive DMARDs during the 12 months prior to the baseline survey had previously taken DMARDs. According to baseline survey and medical records data, the distribution of the number of unique DMARDs ever received by patients was as follows: none (4%), 1 and only 1 (19%), 2 (26%), 3 (19%), and 4 (32%). Concordance was excellent between patient self report and medical records, with 99% of patients during baseline survey correctly reporting each DMARD documented by the medical record as being in use. Most (83%) patients reported DMARD dose(s) that were consistent with medical record dose reports.

4 RA and Process of Care Measurement 887 Table 2. Joint and global status associated with medical record defined disease activity categories* Symptom or sign documented in medical record Mild (n 42) Moderate (n 149) Severe (n 377) Any joint pain Any joint swelling Any joint synovitis Any joint worsened Provider assessment of poor global status Provider assessment of worsened global status Provider assessment of poor or worsened global status Patient report of poor global status Patient report of worsened global status Patient report of poor or worsened global status Worsened with DMARD or steroid Worsened with NSAID or analgesic Any of the above * Values are the percentage of patients with the specified symptom or sign based on abstraction of all clinical encounters documented in the patient s medical record during the 12-month abstraction period prior to the baseline patient report survey. DMARD disease-modifying antirheumatic drug; NSAID nonsteroidal antiinflammatory drug. Patients characterized as having mild disease, by definition, do not have any of the following: joint pain, swelling, or synovitis; evidence for worsening joint symptoms; provider assessment of poor or worsening global status; or evidence for worsening with DMARDs, steroids, NSAIDs, or analgesics. It is likely that these patients are either in remission, or alternatively are asymptomatic as a result of their medication management. Patient-reported health status and use of clinical visits. Patients had substantial disease burden. The mean SD SF-12 physical component score (PCS) was 37 9, HAQ score was , and RA Activity Score derived from RADAI (20,21) was (range 0 10). Symptoms and process stratified by disease activity level as defined by medical records are shown in Table 2. All patients had at least 1 clinical encounter within the 12-month abstraction period. Most (86%) had at least 1 rheumatologist visit, and 21% had at least 1 visit with an orthopedist, neurologist, or neurosurgeon. The mean number of clinical encounters within 12 months was 11, including a mean SD of primary care encounters and rheumatology encounters. Validity of the medical record based disease activity score. Significant differences in health status scores across the 3 disease activity categories derived from medical records are shown in Table 3. Mean SD HAQ scores were for patients with minimal activity, for those with moderate activity, and (P ) for patients with severe disease activity. Patientreported mean SD RA disease activity scores reflecting the 6 months prior to the baseline survey were , , and for severe, moderate, and minimal medical record based disease activity, respectively (P ). Mean SD SF-12 PCS scores were 36 9 for patients with severe disease activity, 40 9 for patients with moderate activity, and 41 8 for patients with minimal activity (P ). The relationship between use of DMARD-associated drugs during 6-month and 12-month and the medical record based disease activity scores is shown in Table 4. As the number of 3-month blocks showing the worst disease category sustained by patients increased, use of DMARD-associated interventions increased. For example, across 12 months, a change in DMARD was noted for 36%, 57%, and 74% of patients with severe disease as the number of during which criteria for severe disease activity increased from 1 to 2 to 3, respectively (P ). We saw a similar pattern of changes in the prevalence of DMARD use as the number of with moderate activity increased from 1 (21%) to 2 (37%) to 3 (45%) (Table 4). Because some clinicians intervened with systemic corticosteroids, we also present data regarding the initiation or change in dose of systemic corticosteroids alone or in combination with DMARD changes (31). The proportion of patients with evidence for severe and moderate disease activity who received a new DMARD (or systemic corticosteroid) drug or dose is shown in Table 5 as a function of 3 allowable for receipt of the intervention. The proportion of patients ever meeting the severe disease activity criteria during the 12-month study period who had a change in drug or dose was 57% within 3 months of first meeting the disease activity criteria, 62% within 6 months, and 80% within 12 months (P ). We observed a similar pattern for patients meeting criteria for moderate disease as their most active category: 26% received a change in drug or dose within 3 months, 32% within 6 months, and 46% within 12 months (P ). DISCUSSION RA is a chronic and progressive disease for most patients. Although the disease may be remitting, deformity and destruction of joints due to erosion of cartilage and bone usually develop if the disease is left uncontrolled. In the

5 888 Kahn et al Table 3. Health status associated with medical record defined disease activity categories* Mild (n 42) Moderate (n 149) Severe (n 377) Age, mean SD years Female sex Disease duration 15 years Disease duration 15 years Health status, mean SD SF-12 PCS score (range 0 100) (17) HAQ score (range 0 3) RA Activity Score (range 0 10) Medication use# Use of DMARD ever# Use of corticosteroids ever# DMARD drug newly initiated, or dose or frequency changed Either DMARD or systemic corticosteroid drug newly initiated, or dose or frequency changed At least 1 consult during 12-month period# Rheumatology consult Orthopedic consult** Neurology or neurosurgery consult Podiatry consult Physical therapy encounter Occupational therapy encounter Any of the above consultations Procedures# Joint imaging Joint injection with corticosteroid Other joint procedure New functional aid * Values are the percentage unless otherwise indicated. SF-12 Short Form 12; PCS Physical Component Scale; HAQ Health Assessment Questionnaire; DMARD disease-modifying antirheumatic drug. Based on patient self report with baseline survey. Comparisons of the 3 listed health status scores are significant with P based on analysis of variance. A higher score is an indication of better health status. Uses a higher score to represent more functional impairment and a score of 0 to represent no functional impairment. Derived from the Rheumatoid Arthritis Disease Activity Index. Defined using the following item: How active in general has your arthritis has been over the last 6 months? On a scale from 0 to 10 where 0 is not at all active, and 10 is extremely active, how active would you say your arthritis has been in the last 6 months? # Based upon abstraction of all clinical encounters documented in the patient s medical record during the 12-month abstraction period prior to the baseline patient report survey. Comparison of these interactions are significant (P 0.05) based upon chi-square test. ** Includes documentation of a referral or a contact with the following specialists: hand surgery, hand surgery orthopedics, orthopedic surgery, orthopedic surgery of the spine, or orthopedics. Includes joint aspiration, joint fusion, joint replacement, synovectomy, tendon surgery, and other joint or perijoint procedures. majority of patients, significant locomotor disability develops within years. Survival of patients with RA is 10 years less than that of matched controls. Given these outcomes for many patients with RA, the goals of RA have often been summarized as follows: 1) the avoidance of joint damage and destruction, 2) early and aggressive treatment of severe or unremitting inflammation, 3) recognition and suppression of ongoing inflammation, and 4) prevention of joint injury (10). Based upon this clinical model, the American College of Rheumatology developed explicit guidelines recommending that patients with active RA should receive a DMARD and patients who continue with active disease should have a change in their DMARD interventions (8). Given the improved outcomes for patients with active disease who receive a DMARD intervention, quality of care measurement should assess the extent to which patients with active RA receive DMARDs. Precise inclusion criteria define which patients can participate in clinical trials regarding DMARD efficacy. Similarly, explicit process measurement must precisely define patients eligible for the intervention whose use defines good process. The present research used data often available for quality of care measurement and categorized patients according to the intensity and duration of disease activity. Our analyses indicated that rates of DMARD (or steroid) interventions are sensitive to whether disease activity is defined as moderate (46%) or severe (62%) and to the disease activity duration being sustained as moderate or severe: 48% for one 3-month time block, 71% for two 3-month, and 84% for three or more 3-month within a 12-month observation period. Rates of DMARD use also vary depending on whether the period for receipt of the DMARD intervention for severe disease is within 3 months (57%), within 6 months (62%), or within 12 months (80%). To estimate how outcomes vary as a function of use or lack of use of DMARD interventions for patients with active RA, one would need to know intensity of disease activity, duration of disease activity, and period of obser-

6 RA and Process of Care Measurement 889 Table 4. Variations in rates of DMARD or systemic corticosteroid interventions as a function of various specifications for the duration of moderate and severe disease activity* Number of 3-month that patient meets criteria for specified disease activity during 12-month period Intervention Exactly 1 time block Exactly 2 Exactly 3 Exactly 4 At least 1 time block At least 2 At least 2 consecutive Moderate disease activity Patients meeting criteria Patients who received therapeutic intervention within 12 months DMARD Systemic corticosteroid DMARD or systemic corticosteroid Severe disease activity Patients meeting criteria Patients who received therapeutic intervention within 12 months DMARD Systemic corticosteroid DMARD or systemic corticosteroid * Values are the percentage. DMARD disease-modifying antirheumatic drug. Based on abstraction of all clinical encounters documented in the patient s medical record during the 12-month abstraction period prior to the baseline patient report survey, the percentage of patients who met criteria for specified disease activity category for the period defined by each column is listed for each treatment regimen within the cells. vation for assessing whether or not the intervention was received. When clinicians or policy makers see quality adherence rates, they want to know how similar or dissimilar their patients are to patients whose data are being described. Our data empirically show enormous variations in rates of adherence as a function of clinical terms that clinicians recognize as important in determining patient need for an intervention, even though terms as clinically detailed as these are rarely included in explicit process measures. The model we have presented depends on categorization of disease activity using medical record data. We observed very different rates of use of medications, consults, and procedures according to disease activity categories. We also demonstrated variations in rates of adherence to the intervention (the THEN statement) as a function of Table 5. Proportion of patients (n 568) receiving a new DMARD or systemic corticosteroid drug or dose regimen for 3 * Change in drug or dose for 3 Within 3 months Within 6 months Within 12 months DMARD Moderate (n 149) Severe (n 377) Systemic corticosteroid Moderate (n 149) Severe (n 377) DMARD or systemic corticosteroid Moderate (n 149) Severe (n 377) * Values are the percentage unless otherwise indicated. DMARD disease-modifying antirheumatic drug. For all patients, the are specified beginning the day the patient first meets criteria for the specified disease activity category. For example, if the patient meets criteria for severe disease activity on January 1, then the 3 during which use of drug intervention would be assessed are January 1 to March 31 (within 3 months), January 1 to June 30 (within 6 months), and January 1 to December 31 (within 12 months). Eighteen months of abstraction data were used for this analysis to allow a longer period of observation for patients who first met criteria for specified disease activity level towards the end of the 12-month period during which disease activity was measured. Patients were assigned to the most severe disease activity category they were eligible for during the 12-month abstraction period.

7 890 Kahn et al disease activity level, duration of that activity level, and allowable time to implement the intervention (a new DMARD drug or dose). Our findings demonstrate the importance of refining explicit process criteria to a level that allows comparisons of patients homogeneous with respect to the need for the intervention and the specification of the intervention (including timing). We have presented a discussion of DMARD interventions for a subset of patients with active RA as a model for assessing explicit process for chronic disease. Many of these patients have a long history of disease and associated treatments. Whereas new or modified treatments can offer improved outcomes for some patients, initiation of new treatment strategies can sometimes be associated with worsening outcomes for other patients with mild or inactive disease. It is for this reason that explicit process measurement restricts the assessment of good quality to demonstration of the specified intervention for patients who need the service. For many clinical circumstances, need is simply defined in terms of demographics (IF the patient is 50 years of age), clinical terms (IF the patient has a fever 38.3 C), or laboratory considerations (IF the patient has serum alanine aminotransferase value 80 IU). However, other explicit measures require consideration of more complex clinical details that must be defined in relation to dynamic clinical characteristics. To capture the aspects of clinical care most likely to influence patient outcomes, quality measurement should be capable of specifying both demographics and the more clinically defined types of patient needs. The measurement model we present was developed to be consistent with both clinical concepts and feasible measurement strategies. The variations in specifications for IF and THEN represent real challenges to practicing clinicians. The observed variations in treatment rates as a function of the intensity and duration of disease activity and the timing of treatment changes demonstrate that clinicians consider these factors in making decisions about treatment changes. Building upon these concepts and analyses, we suggest that explicit process measures be constructed to account for clinical details likely to influence care and outcomes. For patients with chronic disease where waxing and waning symptoms are a reality, process measures should include patient-level trend data, because this is what determines interventions. Attention to the duration of disease activity and to the period for achieving the intervention should be made explicit. Examination of the cohort at baseline interview demonstrated 92% of patients who had ever received DMARDs and 85% currently receiving them. Without understanding the clinical model for when to adjust DMARD drug or dose, quality might be interpreted here as excellent. However, the clinical model based on randomized clinical trial data demonstrated better outcomes for patients with RA with ongoing or worsening moderate and severe disease activity if they were treated with a change in DMARD or dose. Empirical data also demonstrate irreversible joint damage associated with delays in DMARD use (9,10,32). We observed that 6 and 12 months after a patient had moderate activity, only 23% and 24% of patients, respectively, received a change in their DMARD. We observed that within 6 and 12 months after severe activity was noted, only 50% and 68% of patients with severe disease, respectively, received a DMARD adjustment. We urge providers and those responsible for systems of care treating patients with RA to systematically and serially document disease activity during clinical encounters. Using a centralized, electronic format is likely to be an efficient strategy that will permit patients and providers to review trends in disease activity. When activity worsens, the timing and intensity of such changes in patient status should be documented and consideration should be given to changes in DMARD drug or dose. Consideration, discussion, and recommendations for and against therapeutic changes should be noted. Recommendations should be documented and if no changes in therapeutics are made, reasons for no change should also be noted. This type of intervention would help providers and patients systematically review patients history and options. Performance data based upon serial review of efficiently collected information are likely to be welcomed by clinicians, as they would specify use of interventions in relation to time, disease activity, and observation period. 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