New model for treating rheumatoid arthritis patients improves quality of care, reduces costs

Rheumatoid arthritis is a chronic disease that causes pain, stiffness, swelling and limitation in the motion and function of multiple joints. Though joints are the principal body parts affected by RA, inflammation can develop in other organs as well. An estimated 1.3 million Americans have RA, and the disease typically affects women twice as often as men.

AIM FARTHER is a new value-based, population-care model. AIM FARTHER was designed and tested on 2,378 RA patients cared for by 17 rheumatologists in the Geisinger Health System in Central Pennsylvania. The model's name stands for Attribution, Integration, Measurement, Finances and Reporting of Therapies. The rheumatologists launched the program in August 2012 using a new strategic approach to care delivery. Significant improvement in quality of care and cost were noted at 22 months of follow up. Cost savings tallied from de-escalating use of costly biologic drugs came to $720,000 for 2013. The study's authors projected a savings estimate of $1.2 million for 2014.

"We recognized the importance of objectively and routinely measuring disease activity, and using that information to engage our patients and drive a new systematic strategic approach to rheumatoid arthritis care," said Eric Newman, MD, director of rheumatology for the Geisinger Health System and the program designer. "By using people, process, and information technology in new and novel ways, we hoped to be able to improve the lives of those that we serve -- our patients."

The AIM FARTHER care model includes seven components: registry development; defining roles and attribution; integration of primary and specialty care; a new strategic approach to RA care; RA quality measure bundle development; task management and performance reporting; and a new financial incentive model. The RA quality measure bundle included eight measures: RA on disease-modifying anti-rheumatic drug (DMARD), active RA on DMARD, RA with Clinical Disease Activity Index (CDAI) measurement, RA at low disease activity, tuberculosis testing if on a biologic, influenza vaccination, pneumococcal vaccination, and low density lipoprotein (LDL) level checked.

Using a specialized software system (PACER™) that collects information from patients (via a touchscreen questionnaire), physicians, nurses and the electronic health record, Geisinger Health System rheumatologists created a patient level scorecard to measure RA patient care gaps, enabling these care gaps to be reliably closed at the clinic visit and between visits. The individual patient scorecard results were then rolled up into performance reports at the provider, department and division level and shared transparently with each other to improve overall patient care and cost savings.

The study's authors reported that 40 percent of the 2,378 RA patients tracked had achieved 100 percent of their applicable quality measures at 22 months, compared to only 22 percent achieving this mark at the beginning of the study. They noted significant improvement in all the quality measures tracked except active RA on DMARD, which started at 92 percent and rose to 93.

"By using industry-vetted problem solving techniques and quality improvement methodology, we were able to design, test and implement a new model of care that has shown improvement in quality and reduction in cost beyond what I had hoped," said Dr. Newman. "The success is not due to any one individual, but rather rests on the following strengths: meaningful involvement of all members of the rheumatology team, holding ourselves accountable, dedicating the time needed to perform the work, and creating an internal forum to discuss quality improvement on a regular basis. This approach moved our rheumatology team from engagement to buy-in to ownership. The result is an RA population management program that is sustainable yet evolving, as we challenge ourselves to continuously improve the quality of care for our patients with rheumatic disease."