title: Variations and practice in the care of patients with rheumatoid arthritis: quality and cost of care.
abstract: BACKGROUND
  Variability in treatment is linked to lower quality of care and higher costs. Rheumatoid arthritis (RA) is a chronic inflammatory disease for which care and management may vary considerably among rheumatologists. The extent of this variability and its cost ramifications have not been widely studied. This prospective study evaluated the quality and variability in care and quantified the potential cost implications.
  
  
  METHODS
  We used Clinical Performance and Value® vignettes to measure the quality of RA care among community-based rheumatologists. Three online Clinical Performance and Value® vignettes--representing patients likely seen in practice with mild disease activity (case A), worsening disease activity (case B), and stable disease with a complicating comorbidity (case C)--were administered to each rheumatologist. Responses were scored against evidence-based criteria. Costs were computed using current (2011) Medicare pricing. Data were analyzed using t test and fixed-effects analysis of variance.
  
  
  RESULTS
  One hundred eight board-certified rheumatologists (72% were male; mean age, 49.1 years) completed the study. Overall quality scores averaged 61.3%. Those employed by a health system or in a multispecialty practice were more likely to score higher. Highest combined scores for diagnosis and treatment were evident with case A (61.7%) and lowest with case C (46.7%). Up to 79% of rheumatologists ordered at least 1 laboratory test that was considered unnecessary by study protocol criteria, incurring a mean excess cost of $37.85 per physician per case. Up to 26.9% rheumatologists prescribed biologic agents that were not indicated based on American College of Rheumatology treatment guidelines, resulting in additional costs of $2041 per patient per month.
  
  
  CONCLUSIONS
  In this study, we observed a wide range of reported practice variability by rheumatologists in the management of RA. This included unnecessary testing and use of biologic agents that increased the costs of treatment. Opportunities for quality improvement and cost control exist in the management of RA.
authors.affiliation: From *QURE Healthcare, San Rafael, CA; †Faculty of Medicine, University of the Philippines, Manila, Philippines; ‡Oregon State University, Corvalis, OR; §Crescendo Biosciences, South San Francisco, CA; ∥School of Economics, University of the Philippines, Quezon City, Philippines; and ¶Global Health Sciences, University of California, San Francisco, CA.
authors.forename: Lisa
authors.initials: L
authors.lastname: DeMaria
authors.forename: Maria Czarina
authors.initials: MC
authors.lastname: Acelajado
authors.forename: Jeff
authors.initials: J
authors.lastname: Luck
authors.forename: Hui
authors.initials: H
authors.lastname: Ta
authors.forename: David
authors.initials: D
authors.lastname: Chernoff
authors.forename: Jhiedon
authors.initials: J
authors.lastname: Florentino
authors.forename: John W
authors.initials: JW
authors.lastname: Peabody
mesh_terms: D000328:Adult; D018501:Antirheumatic Agents / Q000627:therapeutic use; D001172:Arthritis, Rheumatoid / Q000188:drug therapy*; D001688:Biological Products / Q000627:therapeutic use; D003362:Cost-Benefit Analysis; D019468:Disease Management; D005260:Female; D017048:Health Care Costs / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D011787:Quality of Health Care / Q000592:standards*; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D018501:Antirheumatic Agents; D001688:Biological Products