A. Aguirre, MD, Clinical Fellow, Division of Rheumatology, Department of Medicine, University of California, San Francisco;
L. Trupin, MPH, Academic Coordinator, M. Margaretten, MD, Associate Professor, S. Goglin, MD, Assistant Professor, J. Yazdany, MD, MPH, Professor, Division of Rheumatology, Department of Medicine, University of California, San Francisco.
J Rheumatol. 2020 Nov 1;47(11):1712-1720. doi: 10.3899/jrheum.190472. Epub 2020 Feb 15.
To develop and evaluate interventions to improve quality of care in 4 priority areas in an urban safety net adult rheumatology clinic serving a racially/ethnically and socioeconomically diverse patient population.
The Institute for Healthcare Improvement's Model for Improvement was used to redesign clinical processes to achieve prespecified benchmarks in the following areas from 2015 to 2017: 13-valent pneumococcal conjugate vaccine (PCV13) administration among immunocompromised patients; disease activity monitoring with the Clinical Disease Activity Index (CDAI) for patients with rheumatoid arthritis; latent tuberculosis infection (LTBI) screening for new biologic users with RA; and reproductive health counseling among women receiving potentially teratogenic medications. We measured performance for each using standardized metrics, defined as the proportion of eligible patients receiving recommended care.
There were 1205 patients seen in the clinic between 2015 and 2017. Regarding demographics, 71% were women, 88% identified as racial/ethnic minorities, and 45% were eligible for at least 1 of the quality measures. Shewart charts for the PCV13 and CDAI measures showed evidence of improved healthcare delivery over time. Benchmarks were achieved for the CDAI and LTBI measures with 93% and 91% performance, respectively. Performance for the PCV13 and reproductive health counseling measures was 78% and 46%, respectively, but did not meet prespecified improvement targets.
Through an interprofessional approach, we were able to achieve durable improvements in key rheumatology quality measures largely by enhancing workflow, engaging nonphysician providers, and managing practice variation.
在为不同种族/民族和社会经济背景的患者服务的城市医疗保障成人风湿病诊所的 4 个优先领域，开发和评估旨在改善医疗服务质量的干预措施。
采用美国卫生保健改进研究所的改善模式（Model for Improvement），对临床流程进行重新设计，以便在 2015 年至 2017 年期间在以下领域达到预定基准：13 价肺炎球菌结合疫苗（PCV13）在免疫功能低下患者中的应用；类风湿关节炎患者的疾病活动监测采用临床疾病活动指数（CDAI）；新使用生物制剂的类风湿关节炎患者的潜伏性结核感染（LTBI）筛查；以及接受潜在致畸药物的女性的生殖健康咨询。我们使用标准化指标来衡量每个领域的表现，将其定义为接受推荐治疗的合格患者比例。
2015 年至 2017 年期间，该诊所共接诊了 1205 名患者。在患者人口统计学方面，71%为女性，88%为种族/民族少数群体，45%符合至少 1 项质量措施的条件。PCV13 和 CDAI 措施的 Shewart 图表显示，随着时间的推移，医疗服务提供得到了改善。CDAI 和 LTBI 措施的基准分别达到了 93%和 91%。PCV13 和生殖健康咨询措施的表现分别为 78%和 46%，但均未达到预定的改进目标。
通过跨专业方法，我们主要通过增强工作流程、利用非医师提供者以及管理实践差异，实现了关键风湿病质量措施的持久改进。
