A Fellow-Led Quality Improvement Initiative to Increase Disease Activity Measurement in a Busy Academic Rheumatology Clinic.

BACKGROUND: The preferred management of rheumatoid arthritis (RA), recommended by the American College of Rheumatology (ACR) and international organizations like the European Alliance of Associations for Rheumatology (EULAR), is the treat-to-target (T2T) strategy, due to its association with improved long-term patient outcomes. Successful implementation requires consistent assessment and documentation of disease activity, commonly using tools such as the Clinical Disease Activity Index (CDAI). However, variability in the use and documentation of disease activity measures exists in academic rheumatology settings.  Methods: This fellow-led quality improvement project utilized a Plan-Do-Study-Act (PDSA) framework to improve CDAI documentation in an academic rheumatology clinic. RA patient encounters were identified in both study periods using International Classification of Diseases, 10th Revision (ICD-10) code M06.9. Baseline (pre-intervention) data were collected retrospectively from July 1, 2022, to April 14, 2023. Following baseline assessment, a needs assessment survey was conducted, and an electronic health record (EHR)-integrated templated dot phrase was implemented as the intervention. Faculty and fellows also received email-based education regarding CDAI use and documentation. Post-intervention data were collected prospectively from April 17, 2023, to June 5, 2023. Pre- and post-intervention CDAI documentation rates were assessed through Epic EHR chart review at the encounter level, and the same patients were not necessarily included in both periods. Qualitative outcomes, including usability, workflow disruption, and perceived note bloat, were assessed through post-intervention provider surveys.

RESULTS: Baseline data indicated 261 RA encounters, with only two containing documented CDAI scores. Following the intervention, CDAI was documented in 39 out of 54 RA encounters. Post-intervention surveys revealed that 100% of providers found the dot phrase useful, and 75% reported improved clinical behaviors related to disease activity assessment.  Conclusions: A simple EHR-based intervention, combined with provider engagement, significantly increased CDAI documentation, highlighting how fellow-led quality improvement initiatives may improve implementation of guideline-concordant care in rheumatology. These findings are consistent with prior research showing that EHR templates improve documentation efficiency and reportability and suggest that such interventions can support more effective adherence to ACR guidelines for rheumatoid arthritis management.