ATLANTA – Opportunities to escalate or deescalate medications for patients with rheumatoid arthritis via an electronic health record at the point of care led rheumatologists at the Geisinger Medical Center in Danville, Pa., to increase the number of such decisions in their practice.
“Opportunities for escalation and de-escalation of therapy are common, even in a well-managed RA population,”, director of the department of rheumatology at Geisinger, said in a presentation at the annual meeting of the American College of Rheumatology. “In our hands, over a third of the time, there was an opportunity to change therapy.”
Dr. Newman and colleagues developed a new treat-to-target tab for their (Patient Centric Electronic Redesign), an EHR-adjacent system that captures patient and provider data and presents the information in different views, based on desired action items. The target in the study was low disease activity or remission, which was assessed using Clinical Disease Activity Index (CDAI) scores.
The treat-to-target tab offered three options to rheumatologists in real time when meeting with a patient: an escalation opportunity, which was defined as the patient’s two most recent CDAI scores showing moderate to high disease activity; and a deescalation opportunity, defined as a look-back up to 1 year during which at least two CDAI measures were within low to-moderate disease range. There was also a third “leave-alone” option to neither escalate nor deescalate therapy, but the rheumatologist was prompted to explain why if that option is selected, Dr. Newman noted.
In the first phase of releasing the treat-to-target tab, there was low adoption among the 17 rheumatologists at Geisinger: 82% of rheumatologists did not use the tab for escalation therapy, and 64% did not use the tab for deescalation therapy.
That prompted Dr. Newman and colleagues to develop a new version of the treat-to-target tab for phase 2 of the program. “Once they complete their CDAI, if there’s an opportunity, there would be a bright orange button that would glow right in front of them,” Dr. Newman said. “It was really hard to miss, and all they would have to do is click it and it would bring them right to the treat-to-target tab.”
To increase rheumatologists’ use of the new treat-to-target tab, the amount of time spent using the tab and making decisions is presented to them, he said. “It’s actually now part of our quality measure bundle, so every month, they get a leaderboard to see how they compare with their partners,” he noted. “It’s a great way to drive down variability and get everybody approaching the same sort of mean.”
Overall, between July 2018 and May 2019, there were 1,428 treat-to-target opportunities, consisting of 34.2% of RA office visits. Of these, 11.3% were escalation opportunities and 22.9% were deescalation opportunities, Dr. Newman said.
Between phase 1 and phase 2, the rheumatologists’ nonuse of the treat-to-target tab decreased from 82% to 36% for escalation opportunities, and decisions to escalate therapy increased from 10% to 46%. Similarly, nonuse of the treat-to-target tab for deescalation therapy decreased from 64% to 34%, and decisions to deescalate therapy increased from 5% to 17%.
In 49% of escalation opportunities and 80% of deescalation opportunities in phase 2 of the program, rheumatologists made the decision to leave the patient alone. The reasons for not escalating therapy for a patient included an inaccurate CDAI (34%), patient decision (15%), risks outweighing the benefits (15%), and other (37%). “This is interesting, because if you take 49% times 34%, that means that only 17% of the time they felt it didn’t represent what was going on in our department, which is not what we heard from them verbally before this project,” he said. For deescalation opportunities in which the rheumatologist left the patient alone, the most common reasons were hard-to-control disease (46%), patient preference (29%), and poor prognostic factors (25%).
“Keep in mind, some of these patients may have actually already been deescalated prior to this,” Dr. Newman noted. “We’ve actually done some previous work 3 years ago – we provided a visual signal to our physicians that there was a deescalation opportunity, so we may have already accounted for that portion of the population to some extent.”
Dr. Newman said a future goal of the treat-to-target system is to developed more specific treat-to-target strategies to improve the “signal-to-noise” ratio in the system. “Now [that] it’s fully embedded into our routine RA care delivery across our system, our next steps are going to be to use this tool to proactively drive value-concordant decision making and monitor the effect this has on both disease control as well as cost of care,” he said.
Dr. Newman reported no relevant financial disclosures.
SOURCE: Newman ED et al. Arthritis Rheumatol. 2019;71(suppl 10).