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  • Measure Summary
  • NQMC:010529
  • Oct 2015
  • NQF-Endorsed Measure

Disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis: percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.
National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

This is the current release of the measure.

This measure updates previous versions:

  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of members who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).

Rationale

Disease modifying anti-rheumatic drugs (DMARDs) modify the disease course of rheumatoid arthritis (RA) through attenuation of the progression of bony erosions, reduction of inflammation and long-term structural damage. The utilization of DMARDs is also expected to provide improvement in functional status.

RA is a chronic autoimmune disorder often characterized by progressive joint destruction and multisystem involvement. It affects approximately 2.5 million Americans, and affects women disproportionately (Hochberg & Spector, 1990; McDuffie, 1985; Alarcon, 1995). There is no cure; consequently, the goal of treatment is to slow the progression of the disease and thereby delay or prevent joint destruction, relieve pain, and maintain functional capacity.

Evidence-based guidelines support early initiation of DMARD therapy in patients diagnosed with RA. These guidelines include the American College of Rheumatology (ACR) Subcommittee on Rheumatoid Arthritis Guidelines: Guidelines for the Management of Rheumatoid Arthritis (Harris & Zorab, 1997). All patients with RA are candidates for DMARD therapy, and the majority of the newly diagnosed should be started on DMARD therapy within three months of diagnosis.

The American Pain Society's Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis, and Juvenile Chronic Arthritis (2002) notes that almost all people with RA require pharmacotherapy with a DMARD.

Evidence for Rationale

Alarcon GS. Epidemiology of rheumatoid arthritis. Rheum Dis Clin North Am. 1995 Aug;21(3):589-604. [144 references] PubMed External Web Site Policy

Glenview (IL): American Pain Society; 2002. Guideline for the management of pain in osteoarthritis, rheumatoid arthritis, and juvenile chronic arthritis. p. 76-80.

Harris ED, Zorab R, editor(s). Rheumatoid arthritis. Philadelphia (PA): WB Saunders Company; 1997.

Hochberg MC, Spector TD. Epidemiology of rheumatoid arthritis: update. Epidemiol Rev. 1990;12:247-52. [48 references] PubMed External Web Site Policy

McDuffie FC. Morbidity impact of rheumatoid arthritis on society. Am J Med. 1985 Jan 21;78(1A):1-5. PubMed External Web Site Policy

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Primary Health Components

Rheumatoid arthritis; disease modifying anti-rheumatic drug (DMARD) therapy

Denominator Description

Members age 18 years and older as of December 31 of the measurement year who had two of the following with different dates of service on or between January 1 and November 30 of the measurement year:

  • Outpatient visit, with any diagnosis of rheumatoid arthritis
  • Nonacute inpatient discharge, with any diagnosis of rheumatoid arthritis

See the related "Denominator Inclusions/Exclusions" field.

Numerator Description

Members who had at least one ambulatory prescription dispensed for a disease modifying anti-rheumatic drug (DMARD) during the measurement year (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

  • Rheumatoid arthritis (RA) is a chronic inflammatory disease in which the immune system attacks healthy joints (Centers for Disease Control and Prevention [CDC], 2012). It causes inflammation and destruction of joints and can also damage organs (American College of Rheumatology [ACR], 2012). RA is progressive, but early intervention with disease-modifying anti-rheumatic drugs (DMARD) can help preserve function and prevent further damage to joints (ACR, 2012).
  • Arthritis and related conditions, including RA, cost the United States (U.S.) economy $81 billion in direct costs, such as medical expenses, and $47 billion in indirect costs, such as lost wages and disability payments (CDC, 2007).
  • People with persistent RA are at greater risk for premature death from heart-related problems and other conditions (Symmons & Gabriel, 2011).
  • RA affects 1.3 million Americans, and affects nearly three times as many women as men (Helmick et al., 2008).
  • Although there is no cure for RA, DMARDs may effectively protect joints and minimize inflammation in other organs, slowing progression of the disease and reducing pain (CDC, 2012).

Evidence for Additional Information Supporting Need for the Measure

American College of Rheumatology (ACR). Rheumatoid arthritis. [internet]. Atlanta (GA): American College of Rheumatology (ACR); 2012 [accessed 2014 Jun 17].

Centers for Disease Control and Prevention (CDC). National and state medical expenditures and lost earnings attributable to arthritis and other rheumatic conditions--United States, 2003. MMWR Morb Mortal Wkly Rep. 2007 Jan 12;56(1):4-7. PubMed External Web Site Policy

Centers for Disease Control and Prevention (CDC). Rheumatoid arthritis. [internet]. Atlanta (GA): Centers for Disease Control and Prevention (CDC); 2012 [accessed 2014 May 30].

Helmick CG, Felson DT, Lawrence RC, Gabriel S, Hirsch R, Kwoh CK, Liang MH, Kremers HM, Mayes MD, Merkel PA, Pillemer SR, Reveille JD, Stone JH, National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part I. Arthritis Rheum. 2008 Jan;58(1):15-25. PubMed External Web Site Policy

National Committee for Quality Assurance (NCQA). The state of health care quality 2015. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. 205 p.

Symmons DP, Gabriel SE. Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nat Rev Rheumatol. 2011 Jul;7(7):399-408. PubMed External Web Site Policy

Extent of Measure Testing

All HEDIS measures undergo systematic assessment of face validity with review by measurement advisory panels, expert panels, a formal public comment process and approval by the National Committee for Quality Assurance's (NCQA's) Committee on Performance Measurement and Board of Directors. Where applicable, measures also are assessed for construct validity using the Pearson correlation test. All measures undergo formal reliability testing of the performance measure score using beta-binomial statistical analysis.

Evidence for Extent of Measure Testing

Rehm B. (Assistant Vice President, Performance Measurement, National Committee for Quality Assurance, Washington, DC). Personal communication. 2015 Mar 16.  1 p.

State of Use

Current routine use

Current Use

Accreditation

Decision-making by businesses about health plan purchasing

Decision-making by consumers about health plan/provider choice

External oversight/Medicaid

External oversight/Medicare

External oversight/State government program

Internal quality improvement

Pay-for-reporting

Public reporting

Measurement Setting

Ambulatory/Office-based Care

Hospital Inpatient

Hospital Outpatient

Managed Care Plans

Professionals Involved in Delivery of Health Services

Pharmacists

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

On or between January 1 and November 30 of the measurement year

Denominator Sampling Frame

Enrollees or beneficiaries

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Institutionalization

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Time window brackets index event

Denominator Inclusions/Exclusions

Inclusions
Members age 18 years and older as of December 31 of the measurement year who had two of the following with different dates of service on or between January 1 and November 30 of the measurement year. Visit type need not be the same for the two visits.

  • Outpatient visit (Outpatient Value Set), with any diagnosis of rheumatoid arthritis (Rheumatoid Arthritis Value Set)
  • Nonacute inpatient discharge, with any diagnosis of rheumatoid arthritis (Rheumatoid Arthritis Value Set). To identify nonacute inpatient discharges:
    1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set).
    2. Confirm the stay was for nonacute care based on the presence of a nonacute code (Nonacute Inpatient Stay Value Set) on the claim.
    3. Identify the discharge date for the stay.

Note:

  • Members must have been continuously enrolled during the measurement year.
  • Allowable Gap: No more than one gap in enrollment of up to 45 days. To determine continuous enrollment for a Medicaid beneficiary for whom enrollment is verified monthly, the member may not have more than a 1-month gap in coverage.

Exclusions

  • A diagnosis of HIV (HIV Value Set) any time during the member's history through December 31 of the measurement year. (Optional)
  • A diagnosis of pregnancy (Pregnancy Value Set) any time during the measurement year. (Optional)

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Exclusions/Exceptions

Medical factors addressed

Numerator Inclusions/Exclusions

Inclusions
Members who had at least one ambulatory prescription dispensed for a disease modifying anti-rheumatic drug (DMARD) during the measurement year

  • There are two ways to identify members who received a DMARD: by claim/encounter data and by pharmacy data. The organization may use both methods to identify the numerator, but a member need only be identified by one method to be included in the numerator.
    • Claim/Encounter Data. A DMARD prescription (DMARD Value Set) during the measurement year
    • Pharmacy Data. Members who were dispensed a DMARD during the measurement year on an ambulatory basis (refer to Table ART-C in the original measure documentation for a list of DMARDs).

Exclusions
Unspecified

Value Set Information
Measure specifications reference value sets that must be used for HEDIS reporting. A value set is the complete set of codes used to identify the service(s) or condition(s) included in the measure. Refer to the NCQA Web site External Web Site Policy to purchase HEDIS Volume 2, which includes the Value Set Directory.

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Pharmacy data

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Analysis by subgroup (stratification by individual factors, geographic factors, etc.)

Description of Allowance for Patient or Population Factors

This measure requires that results are reported separately for the commercial, Medicaid, and Medicare product lines.

Standard of Comparison

External comparison at a point in, or interval of, time

External comparison of time trends

Internal time comparison

Original Title

Disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis (ART).

Measure Collection Name

HEDIS 2016: Health Plan Collection

Measure Set Name

Effectiveness of Care

Measure Subset Name

Musculoskeletal Conditions

Submitter

National Committee for Quality Assurance - Health Care Accreditation Organization

Developer

National Committee for Quality Assurance - Health Care Accreditation Organization

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

National Committee for Quality Assurance's (NCQA's) Measurement Advisory Panels (MAPs) are composed of clinical and research experts with an understanding of quality performance measurement in the particular clinical content areas.

Financial Disclosures/Other Potential Conflicts of Interest

In order to fulfill National Committee for Quality Assurance's (NCQA's) mission and vision of improving health care quality through measurement, transparency and accountability, all participants in NCQA's expert panels are required to disclose potential conflicts of interest prior to their participation. The goal of this Conflict Policy is to ensure that decisions which impact development of NCQA's products and services are made as objectively as possible, without improper bias or influence.

Endorser

National Quality Forum

NQF Number

0054

Date of Endorsement

2014 Nov 10

Measure Initiative(s)

Physician Quality Reporting System

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2015 Oct

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates previous versions:

  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2015: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2014. various p.

Source(s)

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 1, narrative. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical specifications for health plans. Washington (DC): National Committee for Quality Assurance (NCQA); 2015. various p.

Measure Availability

Source available for purchase from the National Committee for Quality Measurement (NCQA) Web site External Web Site Policy.

For more information, contact NCQA at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

Companion Documents

The following are available:

  • National Committee for Quality Assurance (NCQA). The state of health care quality 2015. Washington (DC): National Committee for Quality Assurance (NCQA); 2015 Oct. 205 p.
  • National Committee for Quality Assurance (NCQA). HEDIS 2016: Healthcare Effectiveness Data and Information Set. Vol. 2, technical update. Washington (DC): National Committee for Quality Assurance (NCQA); 2015 Oct 1. 12 p.

For more information, contact the National Committee for Quality Assurance (NCQA) at 1100 13th Street, NW, Suite 1000, Washington, DC 20005; Phone: 202-955-3500; Fax: 202-955-3599; Web site: www.ncqa.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI on June 20, 2006. The information was not verified by the measure developer.

This NQMC summary was updated by ECRI on January 31, 2007. The updated information was not verified by the measure developer.

This NQMC summary was updated by ECRI Institute on February 28, 2008. The information was verified by the measure developer on April 24, 2008.

This NQMC summary was updated by ECRI Institute on March 12, 2009. The information was verified by the measure developer on May 29, 2009.

This NQMC summary was updated by ECRI Institute on January 30, 2010 and on May 18, 2011.

This NQMC summary was retrofitted into the new template on June 29, 2011.

This NQMC summary was updated by ECRI Institute on June 1, 2012, April 2, 2013, January 20, 2014, January 14, 2015, and again on January 7, 2016.

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