Development of Cardiovascular Quality Indicators for Rheumatoid Arthritis: Results from an International Expert Panel Using a Novel Online Process

Abstract

Objective-Patients with rheumatoid arthritis (RA) have a high risk of premature cardiovascular disease (CVD). We developed CVD quality indicators (QIs) for screening and use in Rheumatology clinics.Methods-A systematic review of the literature on CVD risk reduction in RA and the general population was conducted. Based on the best practices identified from this review, a draft set of 12 candidate QIs were presented to a Canadian panel of rheumatologists and cardiologists (n=6) from three academic centers to achieve consensus on the QI specifications. The resulting 11 QIs were then evaluated by an online modified-Delphi panel of multidisciplinary health professionals and patients (n = 43) to determine their relevance, validity and feasibility in three rounds of online voting and threaded discussion using a modified RAND/UCLA Appropriateness Methodology.Results-Response rates for the online panel were 86%. All 11 QIs were rated as highly relevant, valid and feasible (median rating ≥7 on a 1-9 scale) with no significant disagreement. The final QI set addresses the following themes: communication to primary care about increased CV risk in RA, CV risk assessment, defining smoking status and providing cessation counseling, screening and addressing hypertension, dyslipidemia and diabetes, exercise recommendations, body mass index screening and lifestyle counseling, minimizing corticosteroid use and communicating to patients at high risk of CVD about the risks/benefits of non-steroidal antiinflammatory drugs. Conclusion-ElevenQIs for CVD care in RA patients have been developed and are rated as highly relevant, valid and feasible by an international multidisciplinary panel.

A Systematic Review of Quality Measures for Inflammatory Arthritis

“…From the 13 sources ( 16,17 , and 1 was a pan-European set 18 ). Most of the sets were for RA 6,7,9,11,12,13,[15][16][17][18] (n = 10, 77%) with 1 each (8%) for JIA 10 , PsA 14 , and inflammatory arthritis 8 . No sets were found for ReA and none accepted for AS.…”

“…Similarly, there was variability in the consensus procedures used to finalize the measurement sets: a modified Delphi in conjunction with Nominal Group Technique in 1 set 10 , a modified RAND/University of California, Los Angeles (UCLA) Appropriateness Method in 4 sets 11,12,16,17 , an online modified Delphi using a platform called ExpertLens (RAND Corp.) in 3 sets 6,7,8 , a modified Delphi in another 17 , and other study-specific consensus methods in 4 sets 9,13,14,15 .…”

“…Interestingly, only a few of these attributes are routinely reported in the studies describing the measure development of the inflammatory arthritis measure sets in this review. For example, to be accepted, quality measures needed variably to be valid 11 , valid and feasible 7,12 , valid and important 6 , valid and relevant 8 , relevant 17 , and applicable and feasible 18 . A few sets did not follow any published attributes for measure development and used the following statements for consensus development: "adequately reflected the quality of disease course monitoring" 16 , "consistent with [previous] recommendations" 9 , or simply included measures with higher "priority" rankings 10,13,14,24 .…”

“…For example, considering the evidence base used for the measure development, only 3 sets of quality measures were based on systematic reviews of existing guidelines and measures 7,16,18 , with another 3 based on nonsystematic literature reviews 6,8,11 . The rest of the measures were developed based on discussions and/or questionnaires with those involved or on existing guidelines.…”

“…More recently, the RAND/UCLA method has been adapted for online panels using a platform called ExpertLens 21 . This platform was used for 3 panels 6,7,8 and has the advantage of including a larger number of participants (40-50) than traditional consensus panels 20 , allowing for broader input. While there is no current standard methodology for quality measure development, at a minimum it is recommended to develop measures based on a high level of evidence (usually from a guideline).…”