title: Application of explicit process of care measurement to rheumatoid arthritis: Moving from evidence to practice.
abstract: 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 time blocks 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, CA 90095-1736, USA. kkahn@mednet.ucla.edu
authors.forename: K L
authors.initials: KL
authors.lastname: Kahn
authors.forename: C H
authors.initials: CH
authors.lastname: MacLean
authors.forename: H
authors.initials: H
authors.lastname: Liu
authors.forename: L Z
authors.initials: LZ
authors.lastname: Rubenstein
authors.forename: A L
authors.initials: AL
authors.lastname: Wong
authors.forename: J O
authors.initials: JO
authors.lastname: Harker
authors.forename: W P
authors.initials: WP
authors.lastname: Chen
authors.forename: D M
authors.initials: DM
authors.lastname: Fitzpatrick
authors.forename: K J
authors.initials: KJ
authors.lastname: Bulpitt
authors.forename: S B
authors.initials: SB
authors.lastname: Traina
authors.forename: B S
authors.initials: BS
authors.lastname: Mittman
authors.forename: B H
authors.initials: BH
authors.lastname: Hahn
authors.forename: H E
authors.initials: HE
authors.lastname: Paulus
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D001172:Arthritis, Rheumatoid / Q000188:drug therapy* / Q000503:physiopathology; D015331:Cohort Studies; D019317:Evidence-Based Medicine; D005260:Female; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D011446:Prospective Studies; D011787:Quality of Health Care; D012219:Rheumatology / Q000592:standards*; D012720:Severity of Illness Index
chemical_list: D000305:Adrenal Cortex Hormones; D018501:Antirheumatic Agents