Novel Indicators for Monitoring Rheumatoid Arthritis Care Quality: A Delphi Consensus Process to Determine Rheumatoid Arthritis-Specific Ambulatory Care Sensitive Conditions

Objectives Ambulatory care sensitive conditions (ACSCs) constitute a set of medical conditions where access to high quality outpatient healthcare services prevents or reduces costly acute care interactions for exacerbations of these diseases. Hospitalizations for ACSCs serve as indicators of access, quality, and performance of the health system.[1] However, the ACSCs in use are largely based on general populations. This study aimed to determine rheumatoid arthritis (RA)-specific ACSCs that may reflect opportunities to prevent possibly avoidable hospitalizations for persons with RA.

Methods A modified e-Delphi process was utilized to build consensus on the preventability and importance of various hospitalization diagnoses occurring in persons living with RA identified from a systematic literature review. Clinical panelists were Canadian and US healthcare providers (rheumatologists, internists, pharmacists, occupational therapists, and physiotherapists) with expertise in the care of persons with RA. Consumer panelists were Canadians living with physician-diagnosed RA. Clinical panelists completed 2 rounds of anonymous voting, with an asynchronous discussion board hosted between rounds. Consumer panelists completed the same process considering the remaining candidate items where consensus had not yet been reached. An interactive webinar preceded a final combined panel round of voting. Consensus criteria were guided by the RAND/UCLA Appropriateness Method.[2,3]

Results Twenty-two clinical and 8 consumer panelists provided expert opinion. There were 46 initial conditions for consideration with 1 condition added by the clinical panel and 2 by the consumer panel. At the conclusion of the 5 voting rounds, 12 conditions were identified as RA-specific ACSCs: those specific to RA disease activity (RA disease flare, vasculitis), RA-related associations and complications (osteoarthritis, osteoporotic fracture, cervical spine instability, anemia/pancytopenia) and acute (upper respiratory infection, septic arthritis) and opportunistic (pneumonia/pneumocystis jirovecii, herpes zoster, tuberculosis reactivation, and other general opportunistic) infections.

Conclusion This study identified 12 potential RA-specific ACSCs. Next steps include monitoring these conditions in a health context to understand their performance as possible RA-specific ACSCs.

References [1.] Rocha JVM. Health Policy Open 2021;2:100030. [2.] Fitch K. The RAND/UCLA appropriateness method user’s manual 2021. RAND Corporation. [3.] Jones J. BMJ 1995;311:376-80.