Dr Ian Rowe developing a national audit of rheumatoid and early inflammatory arthritis
Developing a National Auditfor Rheumatoid and EarlyInflammatory ArthritisIan RoweChair Clinical Affairs Committee, BSR
Outline• The British Society for Rheumatology• Challenges in improving patient outcomes for RA in UK• What is the BSR Biologics Register ?• Approach to the HQIP National Audit in RA• Opportunities
British Society for Rheumatology • Covers England, Wales, Scotland and Northern Ireland Membership • Members include consultant rheumatologists, trainees, allied organisation health professionals and GPs • Closer working with British Health Professionals in Rheumatology (BHPR) Guidelines and • Annual Conference over 2,000 clinicians Education • E learning pilot 2012 • Rheumatology International Journal • HQIP national audit of RA 2012 • Rheumatology conditions seen as outpatient activity rather than Challenges ambulatory care and Long Terms Conditions • Large variation in how services are delivered • Little to inform service specifications • Biologics register managed by BSR , over 25,000 patients BSR Biologics Register • Ankylosing Spondylitis register commenced 2012
Defining Rheumatology A multidisciplinary branch of medicine that deals with the investigation, diagnosis and management of patients with arthritis and other musculoskeletal conditions. This incorporates over 200 disorders affecting joints, bones, muscles and soft tissues, including inflammatory arthritis and other systemic autoimmune disorders, vasculitis, soft tissue conditions, spinal pain and metabolic bone disease. A significant number of musculoskeletal conditions also affect other organ systems. Rheumatology is in the midst of a period of exponential growth in knowledge of the mechanisms of rheumatologic and auto-immune disease, knowledge which is transforming and advancing our treatment options. There is untapped potential for Quality improvement through addressing variation in treatment and care; Innovation through implementing best practice; Prevention of unnecessary disability and improvements in Productivity. British Society for Rheumatology Dec 2011.
RA-Variation in Quality and Outcomes Innovation and Productivity: Early effective treatment needed; RA/IA represent a major health problem; 1 million people (England); cost £8 billion annually (UK); delays in treatment can result in a more aggressive disease; earlier treatment may produce cost savings. Quality Improvement: Major Variations in Care National: Different levels of Care and variation in services i) There is existing wide variation in treatment and outcomes; e.g. only 10% of patients are put onto DMARDs within 3 months of symptom onset in spite of NICE guidelines. ii) Only 63% of patients in acute trusts provided annual review for RA patients to monitor disease progression and emergence of co-morbidities (NAO, 2009; NICE, 2009) International : Poorer Access: Biologic Treatment and Waiting times Europe unsuccessful Disease activity Score 3.2 (mild Spain waits 2 weeks from referral, treatment with a disease) maximum Germany 12 weeks single DMARD U.K. unsuccessful Disease activity Score 5.1 U.K. standard set 3 months from treatment with TWO (severe disease) symptom onset, not met DMARD Meeting Marks in the LSE England was given a 4/10 – the higher marks were awarded to European report in 2012 lowest mark in joint placing with Germany (8/10) and Sweden (9/10). guidelines Poland and SloveniaSource: A Common Disease with Uncommon Treatment ,European Guideline Variations and , Access to Innovative Therapies for Rheumatoid Arthritis LSE June 2102
BSR Biologics Register RA Largest European biologics register for patients with RA• Established 2001• Monitoring long term safety profile• Now >25,000 patients• Cohorts of patients recruited• Six different biologic drugs• Research database: infection risk; comparison between drugs• Established as part of NICE approval for biologics• Funded by pharmaceutical companies• Paper moving to electronic data capture
Potential for other opportunities and use; potentialfor links to other research databases e.g. CPRD; INBANK Policy makers/ Regulators Patients Pharma Biologics Researchers Register Clinicians/ Commissioners Specialist nurses
ARUK- plans for INBANKA national research infrastructure to facilitatecoordinated musculoskeletal research, includingi) a searchable catalogue of extant studies andii) a prospective research database- recruitment to bespoke studies- biological samples- linkage to national datasets
BSR and Healthcare Quality ImprovementPartnership (HQIP) Audit• HQIP invited bids 2011• BSR bid “ National Audit of Rheumatoid and Early Inflammatory Arthritis” accepted 2012
National Institute for Health and ClinicalExcellence (NICE)• RA Guidelines 2009• DMARDs within 3 months of symptom onset• Measure CRP and key components of disease activity (DAS) monthly until disease controlled• Annual review for disease assessment, co-morbidities, MDT, effect of RA on person’s life
3 Key Audit Objectives• Rapid control of joint inflammation: Audit data on new patients for 1 month in rheumatology clinics with follow up data over 3 months. Key outcomes include patient recorded disease severity, satisfaction with access to service, advice and education (NICE). Repeat annually.• Cardiovascular risk factors: Audit at RA annual review (NICE) in collaboration with Primary Care. One month annually.• Ability to work: generate work related outcomes and audit with above.
Healthcare Quality Improvement Partnership(HQIP)National Audit Rheumatoid Arthritis National Audit for 3 years potential to extend for 5 2013 years Spring Implementat ion of Summer Spring 2013 national 2013 audit and Contract let Development data analysis Autumn for national and design of 2012 audit implementati Tender on released for provider July 2012 bidding Specification workshop for proposers Themed workshops, stakeholder engagement, testing and exercising
Minimum Core Dataset to enable futuredevelopments – collect data once• Data direct from the clinical setting• Disease monitoring - adverse events - lifestyle factors - CV risk factors• Collect outcomes important to patients• Inform patient decision making
Improved quality and consistency ofrheumatology services - Challenges andopportunities• Clinical engagement for data collection- user friendly IT• Patient engagement• Continuous data collection• Clinical- routine practice, audit (local and national), revalidation• Discussion with devolved nations• Research (BSRBR, other databases)