PQRS reporting was examined to inform the quality of care provided in both RA and osteoporosis across the entire Medicare program. Using data from the random 5% sample, a total of 1,775 physicians reported on any of the 3 listed osteoporosis PQRS measures in 2009 (). This number represented a minority of physicians treating osteoporosis and fracture patients, as 373,780 additional physicians treating these kinds of patients did not report on an osteoporosis PQRS measure. The median age of the physicians reporting was 50 years, and 71% were male. The majority of physicians (91%) reported on DXA screening (PQRS Measure 39), few (8%) reported on post-fracture care (Measure 40), and 60% reported on prescription medication use for osteoporosis patients (Measure 41).
Characteristics of Physicians* Reporting at Least Once in 2009 for Any Osteoporosis or Rheumatoid Arthritis PQRS Measure
For RA patients using the 100% CMS data, 630 physicians reported on PQRS measures in 2009; most were rheumatologists. The majority reported on DMARD use (Measure 108, 96%); approximately one-third reported on RA disease activity and/or functional status. Physicians reporting PQRS measures generally were similar in age to those not reporting PQRS measures, and a slightly greater proportion of women physicians reported. In 2009, 11.6% of all U.S. rheumatologists reported on DMARD use for their patients through the PQRS program, which was a higher proportion than in 2008 (6.4% of rheumatologists) [data not shown].
describes the patients and reason codes (if present) that physicians used to report whether osteoporosis and RA care was provided, and if not, to provide further explanation(s). For Measure 39 (DXA screening, 4,179 patients) 76% of physicians reported that the patient received a DXA at least once since the age of 60, or were prescribed an osteoporosis medication. The remaining 24% had one or more reason why DXA was not provided. For Measure 40 (osteoporosis management post fracture, 172 patients), only 37.8% of providers reported that the patient received recommended care. Reasons were given for the remaining patients, the most common of which was “other” i.e. “reason not otherwise categorized”. Among 2,351 patients with osteoporosis, their physicians reported that they provided prescription medication for 81.9%.; medical (e.g. comorbidities) and patient-related reasons (e.g. refusal) were less common explanations than non-specific ‘other’ reasons for not providing medication.
Provision of Care and Reasons Care was Not Provided According to Results Reported by Physicians via PQRS, Osteoporosis and Rheumatoid Arthritis Patients from PQRS in 2009*
For RA, physicians reported on DMARD use for 26,408 of their RA patients. A total of 88.8% of patients were described as having received recommended care. Medical reasons (e.g. patient in remission, medical contraindication) were the most common reason given for why care was not provided. A smaller group of RA patients had their RA disease activity or functional status measured. Among the 6,563 patients who had their RA disease activity measured and reported, 14.1% were measured using a non-standardized instrument (e.g. physician gestalt). For the remaining patients, 44.0% of patients were reported by their physicians as being in low disease activity, 32.0% as moderate disease activity, and 9.9% as having high disease activity.
We validated prescription medication use for patients with osteoporosis (Measure 41) and DMARD/biologic use for RA patients (Measure 108) (). The analysis was restricted to patients who had 12 months of part D Medicare coverage prior to and 2 months’ coverage after the relevant osteoporosis or RA physician visit. For patients whose physicians reported that they had prescribed an osteoporosis drug (the majority of all that physicians’ osteoporosis patients), confirmation using pharmacy or infusion codes was obtained for 87% in the previous 12 months or subsequent 2 months from the date of the PQRS claim (). Even for patients whose physicians reported that there was a reason for which care was not provided, 49% had evidence of a filled prescription or infusion for an osteoporosis medication. Overall, 77% of osteoporosis patients treated by physicians reporting on PQRS Measure 41 had evidence that they received a prescription medication. Overall, 74% of patients (across all nodes in the tree) received a prescription osteoporosis medication.
Receipt of Osteoporosis and RA Prescription Medications in 2009 according to PQRS Measure Reporting Status
In RA, the trends were similar (). Among the patients whose physicians reported to the PQRS program that they prescribed a DMARD or biologic in 2009 (Measure 108), evidence of a DMARD or biologic was found for 91% of them. This was higher than for patients of these same doctors when they did not report the PQRS measure (82%). Overall, 86% of patients of physicians who reported on measure 108 had evidence of a DMARD or a biologic. This proportion was 10% higher than the prevalence of DMARD use among patients of physicians not reporting Measure 108 (75.4%). Among all patients in this analysis (i.e. across all nodes in the tree) the overall prevalence of DMARD use was 76%. These results in 2009 were similar to the corresponding results in 2008 (data not shown).
describes factors associated with the PQRS RA Measure 108 that physicians used to describe medical reasons for the patient not receiving a DMARD or biologic. As shown, older age, black race, and a number of comorbidities were significantly associated with physicians reporting a medical reason why the patient was not treated for their RA. In osteoporosis, all reason codes (medical, patient, system, and other) had to be combined given the distribution of the PQRS reason codes. Considering all factors listed in the rows or footnotes in , the only factors significantly associated with a physician reporting that a patient did not receive osteoporosis medications was the presence of chronic kidney disease (multivariable-adjusted odds ratio [OR] = 2.18, 95% CI 1.20 – 3.97) and female gender (OR = 0.54, 95% CI 0.32 – 0.89).
Factors Associated with a Physician-Reported Medical Reason for Which Care Was Not Provided among RA Patients whose Physicians reported on RA Measure 108*