You are here
Quality in rheumatoid arthritis care
Best Practice & Research Clinical Rheumatology
While most rheumatology practices are characterized by strong commitment to quality of care and continuous improvement to limit disability and optimize quality of life for patients and their families, the actual step toward improvement is often difficult. This is because there are still barriers to be addressed and facilitators to be captured before a satisfying and cost-effective practice management is installed. Therefore, this review aims to assist practicing rheumatologists with quality improvement of their daily practice, focusing on care for rheumatoid arthritis (RA) patients.
First we define quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Often quality is determined by the interplay between structure, processes, and outcomes of care, which is also reflected in the corresponding indicators to measure quality of care. Next, a brief overview is given of the current treatment strategies used in RA, focusing on the tight control strategy, since this strategy forms the basis of international treatment guidelines. Adherence to tight control strategies leads, also in daily practice, to better outcomes in patients with regard to disease control, functional status, and work productivity. Despite evidence in favor of tight control strategies, adherence in daily practice is often challenging. Therefore, the next part of the review focuses on possible barriers and facilitators of adherence, and potential interventions to improve quality of care. Many different barriers and facilitators are known and targeting these can be effective in changing care, but these effects are rather small to moderate. With regard to RA, few studies have tried to improve care, such as a study aiming to increase the number of disease activity measures done by a combination of education and feedback. Two out of the three studies showed markedly positive effects of their interventions, suggesting that change is possible. Finally, a simple step-by-step plan is described, which could be used by rheumatologists in daily practice wanting to improve their RA patient care.
Keywords: Quality of care, Quality indicators, Best practice, Barriers, Facilitators, Interventions.
Musculoskeletal disorders such as gout, osteoarthritis, and rheumatoid arthritis (RA) are considered to be among the most burdensome medical conditions
While many practicing rheumatologists will agree that quality of care is an important aspect in rheumatology, the actual step to improve quality of care is often difficult, since rheumatologists do not know where and how to start, and there are no clear strategies available how to approach improvement of quality of care in their clinical practice. This review, with the goal of assisting practicing rheumatologists with their own quality improvement of care, aims to fill this gap. It starts with a brief general introduction on quality of care and its measurement methods. Thereafter, the focus will shift to RA and we will discuss what optimal RA care is, how we can measure whether quality demands are met or not, and how this could be improved. In the latter part, two case descriptions of successful quality improvement projects in RA will be discussed. Finally, we will give practical recommendations to rheumatologists who want to further improve their own performance.
A. What is quality of care and how can you measure it?
Quality of care in itself is a rather abstract term, but more practical descriptions do exist. One of the most commonly used descriptions, developed around 1980 by Donabedian, distinguishes structures, processes, and outcomes of care
Around 1990, the Institute of Medicine (IOM) defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Furthermore, the IOM formulated the following six criteria that pertain to quality of care: Care should be i) safe, ii) effective, iii) patient-centered, iv) timely, v) efficient, and vi) equitable
Knowing how to describe quality of care is a prerequisite for its measurement. Often quality indicators are used to assess quality of care. A quality indicator is “a measurable element of practice performance for which there is evidence or consensus that it can be used to assess the quality, and hence change the quality of care provided.”
B. What is optimal RA care?
The treatment of RA has substantially improved during the last two decades. Until 1990, the use of disease-modifying anti-rheumatic drugs (DMARDs) was limited, due to the belief that DMARDs were too toxic to use for a non-life-threatening disease such as RA , , and . However, these assumptions have changed and the use of DMARDs, both synthetic and biological, in the management of RA has gained prominence. Treatment methods such as a step-up approach, combination therapy and treat-to-target strategies have been developed , , and .
Improvements in care for RA patients have not only been the result of an increase in the number of effective therapeutic options, but also because of the broader insight into the course of the disease and its prognosis. For example, it is evident that active RA is associated with a high risk of cardiovascular morbidity and mortality. Furthermore, it was found that RA treatment should be started at the earliest (in the so-called “window of opportunity”) in order to prevent the occurrence of irreversible joint damage or at least to halt progression of the disease  and  Another terminology used in this context is “hit hard, hit early” (intensive treatment early in the disease course) and “tight control”. Tight control, though being the mainstay of optimal clinical RA care, is not the only facet of good RA care. Shared care with specialized nurses or physician assistants, cardiovascular risk management and the management of comorbidities are some other important aspects of RA care. However, all these aspects cannot be elucidated in detail. Hence, we focus on the tight control principle that currently forms the basis of major treatment guidelines  and .
Tight control, also called ‘treat to target’, can be defined as “frequent assessment of disease activity combined with an objective structured protocol to make treatment changes that maintain low disease activity or remission at an agreed target.”
Various studies have proven the effectiveness of the tight control regime, with the Tight Control of Rheumatoid Arthritis (TICORA) study being one of the first to show the beneficial effects of tight control. In the TICORA study, patients in the tight control group had a significantly better disease outcome after 18 months as compared to the control group with regard to the European League Against Rheumatism (EULAR) good response criteria (82% vs. 44%, p < 0.0001) and the mean decrease in disease activity score (DAS; −3.5 vs. −1.5, p < 0.0001)
After the TICORA study, several studies have replicated these findings, and in 2010 a meta-analysis on the effects of tight control was published. This meta-analysis concluded that patients treated according to the tight control principles had significantly better DAS-28 responses as compared to patients treated with usual care (mean difference = 0.59; p < 0.001)
Although tight control studies so far have focused on reaching remission or low disease activity, secondary analyses have shown that lower disease activity is also associated with improved work productivity, less comorbidity, and lower cardiovascular risk
In summary, due to the complexity of RA and the increasing treatment arsenal, it can be difficult for rheumatologists to provide optimal RA care in all patients. However, it seems that using tight control-based treatment strategies could assist rheumatologists in achieving low disease activity or remission in the majority of their patients, ensuring better clinical outcomes, and promoting better work productivity, less comorbidity, and lower cardiovascular risk
C. How can we measure whether optimal RA care is provided?
As mentioned in the first section, quality of care can be assessed using predefined quality indicators for the structure, processes, and outcomes of care  and . With regard to RA, a broadly accepted set of quality indicators is lacking. However, several groups around the world have made an attempt to develop sets of RA quality indicators. Some of these indicator sets are as follows:
Dutch researchers have described one of the first sets, designed to monitor RA disease course in the Dutch Rheumatoid Arthritis Monitoring (DREAM) cohort. This indicator set consists of 10 process, five structure and three outcome indicators and is divided into different subcategories. These subcategories are the measurement of disease activity, structural damage, functionality, follow-up frequency, intensification of pharmacological therapy, prerequisites for measuring disease activity, and patients׳ disease activity (e.g., the percentage of RA patients in remission a year after diagnosis)
Two other groups in Europe have also developed sets of quality indicators. Firstly, the National Health Service in England (NHS) has developed quality indicators for RA, along with indicators for other diseases, in order to standardize improvements in the delivery of primary care
The second European indicator set is developed by the European Musculoskeletal Conditions Surveillance and Information Network (EUMUSC.NET) and contains 14 indicators (one outcome, two structural, and 11 process indicators)
In the United States, the Arthritis Foundation and the ACR have also developed sets of indicators. The extensive set from the Arthritis Foundation comprises 27 process indicators and they can be divided into 17 domains such as time to referral, history and examination, regular follow-up, radiographs of hand and feet, radiographs of cervical spine, DMARDs, folic acid with methotrexate (MTX), osteoporosis prophylaxis, use of glucocorticoids, exercise, assistive devices, surgery, baseline and follow-up studies, methotrexate transminitis (increase in aminotransferases), informing patients about risks (such as risks regarding the use of non-steroidal anti-inflammatory drugs (NSAIDs), DMARDs, glucocorticoids and narcotics), reproductive issues, and finally vaccines
An international task force developed a set of 10 quality indicators, using the Measurement of Efficacy of Treatment in the Era of Outcome in Rheumatology (METEOR) database. This set consists of seven process indicators and three outcome indicators: time to diagnosis, antibodies and radiographic assessment, frequency of visits, disease activity assessment, functional status assessment, remission of disease activity (clinical remission), low disease activity, level of functional limitation, time to first DMARD, and type of first DMARD
Finally, the Australian Rheumatoid Association has proposed a set of three process indicators. These indicators cover measurement of disease activity and comorbidities
It is evident from these seven sets that the majority of these indicators include process measures. Of the 82 indicators, only nine were outcome indicators , , , , , , and . The majority report the “number of times” a certain outcome is measured (process), rather than the actual outcomes themselves. Referring to the triad suggested by Donabedian, which links process, structure, and outcome of care to each other, an imbalance between the different types of indicators in the current sets is quite apparent  and . Furthermore, the availability of many sets for selection may further jeopardize the implementation in daily practice. In conclusion, a better-balanced (more outcome, less process) and more widely accepted indicator set would be instrumental in achieving a uniform measurement of RA care. In the meantime, a rheumatologist willing to measure the quality of his own practice should choose one of the available indicator sets which best reflects what one wants to measure.
D. Is optimal care delivered to RA patients?
As described in this review, the use of tight control strategies is beneficial to RA patients and major treatment guidelines have embraced the tight control strategy , , and . Unfortunately, the existence of these guidelines and the underlying evidence for their efficacy seem to be insufficient to ensure application of tight control in daily practice. This issue has been addressed by several studies, with rather underwhelming results. Here we will briefly summarize some of these studies.
Benhamou et al. assessed the potential gap between daily practice and recommendations on first DMARD prescription in RA in the French multicenter ESPOIR cohort
Around the same time, another European study assessed treatment patterns in early RA patients (ERAN cohort)
Furthermore, in the United States, the prescribing practices of rheumatologists were assessed. In contrast to the ESPOIR and ERAN cohort, this study also included biologic DMARD (bDMARD) prescriptions and compared adherence before and after the publication of the ACR treatment recommendations
The results of these three studies may seem rather disappointing. However, a Dutch study on guideline adherence in the DREAM remission induction cohort yielded more positive results
Finally, in another study using data from the ESPOIR cohort, it was observed that adherence to tight control strategies in daily practice may have real benefits for patients
From the above-described literature data, we can conclude that application of a tight control strategy in daily practice is feasible, but general adherence is not yet optimal , , , , , , and . In addition, it was observed that suboptimal adherence may have negative consequences for patients with regard to disease control, radiographic progression, and functional status.
E. How can you improve RA care?
We have learned from various studies described in the previous section that optimal RA care is not always delivered to patients. The main issue now lies in the methods to improve RA care, for which we need to consider the field of implementation science, an area specifically focusing on bridging the gap between evidence and clinical practice. First, the factors that influence the successful uptake of evidence by physicians (also called “barriers and facilitators” to implementation) are explained, followed by the potential interventions to change clinical practice.
Factors influencing adherence to evidence-based recommendations
Many studies have made an attempt to understand barriers and facilitators associated with implementing change and consequently, different checklists, frameworks, and taxonomies have been developed. In 2013, a systematic review by Flottorp et al. was published, describing the development of a comprehensive checklist (TICD checklist), integrating previous checklists, frameworks, and taxonomies
As described in
Potential interventions to improve care
Recommendations or guidelines can assist rheumatologists in providing optimal clinical care to RA patients, but we have also seen that implementation of guidelines is often difficult , , , and . In the previous section, we have discussed studies that have identified many factors that may influence the successful implementation of change. Now the question remains as to what types of interventions could be applied to improve care and their effectiveness.
Before answering this question, we will first summarize the types of interventions that do exist. The Effective Practice and Organization of Care (EPOC) group is a Cochrane review group specialized in undertaking reviews on all types of interventions that aim to improve health professional practice (
As can be seen in
The EPOC systematic review on educational meetings was published in 2006 and included 81 trials with over 11,000 included health professionals
Audit and feedback
Another EPOC review focused on audit and feedback and this review included 140 different studies
On-screen computer reminders are often used as an intervention and their effectiveness has also been evaluated by EPOC
Taking into account the abovementioned reviews and the determinants of successful implementation, one might wonder if interventions specifically tailored to facilitators or barriers of implementation are more effective than non-tailored interventions. The EPOC tried to answer this question as well, but studies directly comparing “tailored interventions” to “non-tailored interventions” or “no intervention at all” were scarce, and a definitive conclusion was not possible. In spite of this scarcity, the conclusion was that tailored interventions can be effective, but that their effect is variable and tends to be small to moderate at best
In summary, this section described different interventions that could be used when trying to improve quality in clinical practice. The effects of any one of these different interventions are often small to moderate, but some evidence exist that a combination of different interventions is more effective
F. What initiatives exist to specifically improve RA care?
Several studies have tried to specifically improve RA care by introducing different types of interventions. To our knowledge, there is no complete overview of these studies available, so we will discuss three different studies that describe some kind of intervention designed to improve care.
The first example is a pilot study aiming at improvement of disease activity and medication prescription in RA patients by implementing nurse-led DAS-28 measurements
Another example of an attempt to change clinical practice is the Metrix study
In the third and final study, Ledwich and colleagues determined the effects of an Electronic Health Record (EHR) best practice alert (BPA) on vaccination rates in patients with a rheumatic disease using an immunosuppressive drug
Together these three studies show that initiatives are started within rheumatology evaluating strategies to improve quality of care for patients with RA or rheumatic diseases in general. Of these three studies, the latter two have demonstrated beneficial effects with regard to improving care, whereas the first study suggests that monitoring alone without a strict treatment protocol is not effective enough to truly change practice behavior. It is evident from the above studies that efforts have been made to improve the quality of RA care, but the goal has not been achieved yet.
Our conclusions from the previous sections are based on results of published studies. However, it is likely that many initiatives made to improve quality of care have not been detailed in international peer-reviewed journals (publication bias). Two of such quality improvement initiatives previously described only in the Dutch literature will be discussed here.
Both of the described initiatives have been taken from the Sint Maartenskliniek (SMK) in the Netherlands. In this specialized clinic for rheumatology, orthopedic surgery, and rehabilitation medicine, the rheumatology department has implemented nurse-led DAS-28 assessments for all RA patients visiting the outpatient clinic, starting in 2010. Since then, RA patients arrive at the clinic 1 h before their visit with the rheumatologist. Upon arrival, blood is drawn for routine laboratory testing and the patient is seen by a specialized nurse. During this visit, the DAS-28 and HAQ are performed, and the current medication of the patient is discussed in order to identify any side effects or changes that have occurred since the last visit. All the information gathered during the visit with the nurse is provided to the rheumatologist prior to his or her consultation with the patient, increasing the efficiency
After the implementation of nurse-led DAS-28 assessments in the department, it became evident that to obtain reliable DAS-28 scores across the different health-care professionals (nurses, physician assistants, residents, and rheumatologists) who performed the DAS-28, an acceptable level of agreement in the DAS-28 scores is mandatory. Furthermore, as rheumatologists did not perform the DAS-28 themselves anymore, they had to learn to rely on the nurses. Therefore, an interactive and competitive DAS-28 training was designed to increase inter-observer agreement and to improve mutual confidence between rheumatologists and nurses. In this so-called “DAS-28 battle” using elements of serious gaming, rheumatologists and nurses were first trained by an experienced rheumatologist to perform the joint counts needed to calculate the DAS-28. Next, the participants were divided into small groups and were asked to perform a tender and swollen joint count in four different patients. In every group of patients, one “fake patient” was present (usually a partner of a real RA patient) and these persons served as “healthy controls”. This extra twist was added to assess the number of false-positive joints (joint scored as swollen in a healthy control). Blood tests were available, so DAS-28 scores could be calculated and compared immediately. Measurement error and the number of false-positive joints were calculated per team, and the team with the best score on both items was awarded the “Golden Hand”
G. Practical implications
In this review, we have provided an overview of the current status of quality of care in RA. In the first section, we saw that defining and measuring quality of care can be challenging and that different types of quality indicators exist. Next, we described current treatment strategies used in RA, which are based on tight control. Different sets of indicators to measure RA care were discussed thereafter, which was followed by describing different studies assessing adherence to tight control recommendations. Unfortunately, adherence turned out to be suboptimal in most cases. In the subsequent section, we have introduced the field of implementation science that has addressed this issue before, and examples of effective interventions were given. Finally, some of these interventions that are already applied in RA and have led to improvements in care provided to patients were described.
In our opinion, these data show that evidence for the most effective RA treatment is available and that rheumatologists are willing to use this evidence in order to treat their patients to the best they can, but they need to be assisted in doing so. So, how could rheumatologists be assisted in improving their own RA care? In this final section, we will address this theme from two different points of view: the researcher׳s view and the practicing rheumatologist׳s view.
The researcher׳s view
We have seen that different groups around the world have developed RA quality indicators. However, none of these indicators sets are universally accepted, making it difficult to use them in research. While the indicator set formed by the international taskforce of METEOR attempts a more international approach, much more still needs to be done
In addition, far more attention should be given to the translation of evidence into practice. Here we refer to Buchbinder et al., who have recently stated that “investment in discovery research is essentially wasted if implementation research is ignored”
Finally, policy makers and developers of guidelines or practice recommendations should be more aware of the fact that only disseminating guidelines does not suffice to ensure uptake of recommendations in clinical practice. Therefore, any new or updated version of a guideline should be accompanied by an implementation plan or at least some recommendations on how to implement the guideline in daily clinical practice. The AGREE (Appraisal of Guidelines Research & Evaluation) tool is a helpful aid when developing a guideline as the AGREE gives recommendations to develop a high quality guideline. Besides recommendations on topics such as clarity and presentation of the guideline, AGREE also stresses the need for an implementation plan as a supplement with a guideline. In addition, additional materials could be useful, such as a summary document, educational tools or computer support. These additional materials should be provided with the guidelines in order to enhance their use
The Rheumatologist׳s view
In this review, we have tried to answer the question “how can a rheumatologist improve his or her own practice”. Unfortunately, the literature is inconclusive and research in rheumatology is scarce. This problem has been addressed in the previous sections, and we will now propose some simple steps that rheumatology practices could use to improve their quality of care.
When changing current practice, a first step would be to define a manageable goal. For example, “treat your RA patients in such a way that you achieve low disease activity in 60% of all your RA patients after one year”. Of note, the goal of 60% in this example is arbitrary and not based on evidence. Unfortunately, we do not know whether 60% is optimal; however, based on clinical trials this could be a feasible goal to start implementation with.
Next, it is necessary to check the availability of resources to reach the preset goal. For example, see if an up-to-date local RA treatment guideline is available and, if not, try to see that such a guideline will become available. In our experience, guidelines are easier to use in daily practice if they include brief and specific descriptions of what to do in specific situations rather than elaborating on the underlying evidence. For example, provide a step-by-step description on what to do in a patient with active disease. When such a new or updated guideline is finished, all relevant stakeholders (nurses, residents, rheumatologists, pharmacists, etc.) should be informed about this. If necessary, additional actions such as an educational meeting may be needed to improve implementation of the guideline. Apart from a clear treatment guideline, additional resources might be needed. As observed in the TICD checklist by Flottorp, many potential barriers to adherence exist
After all necessary actions are implemented, the next step would be to check at specified intervals if the preset goal has been met. Often, appropriate information for this check is not readily available from the existing systems such as the EHR. One solution could be to conduct a chart review after, for example, 6 months (medical audit), collecting data on disease activity and on what has been done in response. Such a chart review can be very labor intensive if done in many patients, but for feedback purposes a sample from the total patient population is often enough. Using the local treatment protocol, a few aspects of RA care could be checked for (“Is disease activity measured during every routine visit?”; “Is DMARD medication changed in response to active disease?’ and ‘Is low disease activity present?”). Individual data from the patient׳s charts can then be aggregated in order to see if the preset goal has been reached. This chart review would be most useful if all rheumatologists in one practice are involved and individual results are compared. Of note, a safe learning environment is critical when comparing non-anonymized performances among rheumatologists.
Almost always such a chart review will reveal that not all the care is in accordance with the guidelines or the preset goal. Additional measures may be needed to further improve the quality of care and reach the preset goal. When finally those additional measures have resulted in meeting your goal, a new cycle starts and continuous evaluation will be necessary to maintain quality improvement.
The above-mentioned steps are also known as the Plan, Do, Check, Act (PDCA) cycle or the Define, Measure, Analyze, Improve, Control (DMAIC) cycle
- − The translation of scientific evidence on optimal care for patients with RA from clinical trials into clinical practice is difficult, and often suboptimal.
- − To bridge this gap, we need a set of clear and internationally accepted indicators to measure the current quality of care, more research should be done to identify effective interventions and implementation of guidelines should be an integral part of guideline development.
- − In the meantime, rheumatologists wanting to improve their own RA care should start with selecting or developing a local, tight control-based RA treatment protocol as this has shown to have beneficial effects on patient outcomes.
- − When implementing such a protocol in daily practice, a “tight control” strategy can be used comprising three steps: 1) setting a goal and assessing whether this goal is already met, 2) implementing changes if the goal is not yet reached and keep adjusting this until the goal has been reached, and 3) continuously evaluating such preset goals in order to maintain optimal quality of care.
Conflicts of interest
The authors have no conflicts of interest to declare.
-  R. Buchbinder, C. Maher, I.A. Harris. Setting the research agenda for improving health care in musculoskeletal disorders. Nature Reviews Rheumatology. 2015;11:597-605
- * A. Donabedian. Quality of care. How can it be assessed?. JAMA. 1988;260(12)
-  D.C.J. Nash, A. Skoufalos, M. Horowitz. Conceptualizations and definitions of quality. Health care quality: the clinician׳s primer: American college of physician executives. (, 2012) 412
-  Medicine Io. Crossing the quality chasm: a new health system for the 21st century. (, 2001) Washington (DC)
-  J. Markhorst, L. Martirosyan, H. Calsbeek, et al. Stakeholders׳ perspectives on quality indicators for diabetes care: a qualitative study. Quality in Primary Care. 2012;20(4):253-261
-  M. Lawrence, F. Olesen. Indicators of quality in health care. European Journal of General Practice. 1997;3:103-108
-  A. Donabedian. Explorations in quality assessment and monitoring. (Health Administration Press, Ann Arbor, Michigan, 1980)
-  S.J. Lee, A. Kavanaugh. Pharmacological treatment of established rheumatoid arthritis. Best Practice & Research Clinical Rheumatology. 2003;17(5):811-829
-  J.F. Fries. Current treatment paradigms in rheumatoid arthritis. Rheumatology. 2000;39(Suppl. 1):30-35
-  L. Abasolo Alcazar. Triple therapy in rheumatoid arthritis. Reumatologia Clinica. 2014;10(5):275-277
- * M.F. Bakker, J.W. Jacobs, S.M. Verstappen, et al. Tight control in the treatment of rheumatoid arthritis: efficacy and feasibility. Annals of the Rheumatic Diseases. 2007;66(Suppl. 3):iii56-60
-  J.A. van Nies, A. Krabben, J.W. Schoones, et al. What is the evidence for the presence of a therapeutic window of opportunity in rheumatoid arthritis? A systematic literature review. Annals of the Rheumatic Diseases. 2014;73(5):861-870
-  J.S. Smolen, D. Aletaha, J.W. Bijlsma, et al. Treating rheumatoid arthritis to target: recommendations of an international task force. Annals of the Rheumatic Diseases. 2010;69(4):631-637
- * J.S. Smolen, F.C. Breedveld, G.R. Burmester, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Annals of the Rheumatic Diseases. 2015;:1-13
-  P. Kiely, R. Williams, D. Walsh, et al. Early rheumatoid Arthritis N. Contemporary patterns of care and disease activity outcome in early rheumatoid arthritis: the ERAN cohort. Rheumatology. 2009;48(1):57-60
- * L.G. Schipper, L.T. van Hulst, R. Grol, et al. Meta-analysis of tight control strategies in rheumatoid arthritis: protocolized treatment has additional value with respect to the clinical outcome. Rheumatology. 2010;49(11):2154-2164
-  M.A. Stoffer, M.M. Schoels, J.S. Smolen, et al. Evidence for treating rheumatoid arthritis to target: results of a systematic literature search update. Annals of the Rheumatic Diseases. 2015;:1-7
-  L.T. van Hulst, J. Fransen, A.A. den Broeder, et al. Development of quality indicators for monitoring of the disease course in rheumatoid arthritis. Annals of the Rheumatic Diseases. 2009;68(12):1805-1810
-  N. Employers. 2014/15 general medical services (GMS) contract quality and outcomes framework (QOF). (, 2014) 120-122 NHS England Gateway reference: 01264
-  I.F. Petersson, B. Strombeck, L. Andersen, et al. Development of healthcare quality indicators for rheumatoid arthritis in Europe: the eumusc.net project. Annals of the Rheumatic Diseases. 2014;73(5):906-908
-  C.H. MacLean, K.G. Saag, D.H. Solomon, et al. Measuring quality in arthritis care: methods for developing the arthritis foundation׳s quality indicator set. Arthritis and Rheumatism. 2004;51(2):193-202
-  National Committee for Quality Assurance PCfPI. American college of rheumatology. Rheumatoid arthritis physician performance measurement set American medical association and national committee for quality assurance. (, 2008)
-  V. Navarro-Compan, J.S. Smolen, T.W. Huizinga, et al. Quality indicators in rheumatoid arthritis: results from the METEOR database. Rheumatology. 2015;54(9):1630-1639
-  Conditions NCfMAaM. National indicators for monitoring osteoarthritis, rheumatoid arthritis and osteoporosis. (Australian Institute of Health and Welfare, Canberra, 2006)
-  M. Benhamou, N. Rincheval, C. Roy, et al. The gap between practice and guidelines in the choice of first-line disease modifying antirheumatic drug in early rheumatoid arthritis: results from the ESPOIR cohort. The Journal of Rheumatology. 2009;36(5):934-942
-  L.R. Harrold, J.T. Harrington, J.R. Curtis, et al. Prescribing practices in a US cohort of rheumatoid arthritis patients before and after publication of the American college of rheumatology treatment recommendations. Arthritis and Rheumatism. 2012;64(3):630-638
- * M. Vermeer, H.H. Kuper, H.J. Bernelot Moens, et al. Adherence to a treat-to-target strategy in early rheumatoid arthritis: results of the DREAM remission induction cohort. Arthritis Research and Therapy. 2012;14(6):R254
-  C. Escalas, M. Dalichampt, B. Combe, et al. Effect of adherence to European treatment recommendations on early arthritis outcome: data from the ESPOIR cohort. Annals of the Rheumatic Diseases. 2012;71(11):1803-1808
-  W.ø.M. Maksymowych, O. Elkayam, R. Landewé, et al. Impact of failure to Adhere to treat-to-target of rheumatoid arthritis in real world practice: data from the international rheumatoid arthritis biomarker program. (, 2014) Abstract Number: 2912
-  L. Kuusalo, K. Puolakka, H. Kautiainen, et al. Impact of physicians׳ adherence to treat-to-target strategy on outcomes in early rheumatoid arthritis in the NEO-RACo trial. Scandinavian Journal of Rheumatology. 2015;:1-7
- * S.A. Flottorp, A.D. Oxman, J. Krause, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implementation Science. 2013;8:35
Collaboration C. Effective practice and organisation of care (EPOC).
EPOC Taxonomy. 2015;:1-11
http://epoc.cochrane.org/epoc-taxonomyCochrane Collaboration, 2015
- * J.M. Grimshaw, R.E. Thomas, G. MacLennan, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technology Assessment. 2004;8(6):1-72 iii-iv
-  L. Forsetlund, A. Bjorndal, A. Rashidian, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. The Cochrane Database of Systematic Reviews. 2009;2:CD003030
-  N. Ivers, G. Jamtvedt, S. Flottorp, et al. Audit and feedback: effects on professional practice and healthcare outcomes. The Cochrane Database of Systematic Reviews. 2012;6:CD000259
-  K.G. Shojania, A. Jennings, A. Mayhew, et al. The effects of on-screen, point of care computer reminders on processes and outcomes of care. The Cochrane Database of Systematic Reviews. 2009;3:CD001096
-  R. Baker, J. Camosso-Stefinovic, C. Gillies, et al. Tailored interventions to address determinants of practice. The Cochrane Database of Systematic Reviews. 2015;4:CD005470
-  L.T. van Hulst, M.C. Creemers, J. Fransen, et al. How to improve DAS28 use in daily clinical practice?–a pilot study of a nurse-led intervention. Rheumatology. 2010;49(4):741-748
-  J. Pope, C. Thorne, A. Cividino, et al. Effect of rheumatologist education on systematic measurements and treatment decisions in rheumatoid arthritis: the metrix study. The Journal of Rheumatology. 2012;39(12):2247-2252
-  L.J. Ledwich, T.M. Harrington, W.T. Ayoub, et al. Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert. Arthritis and Rheumatism. 2009;61(11):1505-1510
-  A. den Broeder, E. van den Ende, I. Schasfoort, et al. Implementatie van klinimetrieondersteuning in de reumatologische praktijk. Nederlands Tijdschrift voor Reumatologie. 2011;:26-31
-  V.L.N. Straten, A. den Broeder. Naar een eenduidige uitvoering van de DAS28: de ׳DAS28-battle׳. Nederlands Tijdschrift voor Reumatologie. 2012;:10-13
- * Collaboration TA. Appraisal of guidelines for research & evaluation. (St George’s Hospital Medical School, London, 2001)
- * C.R. Nicolay, S. Purkayastha, A. Greenhalgh, et al. Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare. The British Journal of Surgery. 2012;99(3):324-335
a Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Department of Rheumatology, Room ZH 3A-58, De boelelaan 1117, 1081, HV, Amsterdam, The Netherlands
b Sint Maartenskliniek, Department of Rheumatology, Hengstdal 3, 6500, GM, Nijmegen, The Netherlands
c Amsterdam Rheumatology and Immunology Center, VU University Medical Center, Department of Rheumatology, Room ZH 3A-56, De boelelaan 1117, 1081, HV, Amsterdam, The Netherlands
d Radboud University Medical Center, Radboud Institute for Health Sciences, IQ Healthcare, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands
e Amsterdam Rheumatology and Immunology Center, Academic Medical Center, Meibergdreef 9, The Netherlands
Corresponding author. Tel.: +31 20 4445116.
© 2015 Elsevier Ltd, All rights reserved.