Educating Primary Care Providers on

Rheumatoid Arthritis Translates to

Changes in Practice and Referrals:
Results from the RAPID CME Program
Clifton O. Bingham III, MD1; Karen Costenbader, MD, MPH2; Michael Weinblatt, MD2;
Stephen Bender3; Daniel Duch, PhD3
1
John Hopkins University, Baltimore, MD; 2Brigham and Women’s Hospital, Boston, MA; 3Curatio CME Institute, Exton, PA

Rationale
• P
 rovisional diagnosis of RA by PCPs followed by referral to a rheumatologist is crucial for
optimal, evidence-based patient care:
– Reduce joint erosions, prevent lasting disabilities
– Reduce long-term medical costs (eg, joint replacements)
• T
 he RAPID 2007 CME initiative focused on PCP provisional diagnosis of RA and recommended
early referral to a rheumatologist
• Availability of medical claims data
Purpose of the Pilot Study
• For physician participants in the 2007 RAPID CME initiative:
• U
 sing medical claims data, determine if there was any change in the rate of office visits
to a rheumatologist for patients with a diagnosis of RA (“referral” rate) after, compared to
before, the CME activity
• Compare test group “referral” rate to that of nonparticipants (a control group)
• Measure changes in performance in CME activity participants
• Conduct a general, pilot analysis
Data Source
• A
 national-scope medical claims database that represents more than 870,000 US-based
clinicians across all specialties
 – CDM-Charge Detail Master (history from 2001) – providing the most detailed level of
hospital billing information for patient level drug usage, procedures, and diagnoses
in both the inpatient and the outpatient care settings from approximately 600+ hos-
pitals. Hospital data is drawn from operational files and other reference sources. The
database consists primarily of general medical-surgical hospitals but also includes
some specialty hospitals such as children’s and rehabilitation.

Support for the certified educational activities and outcomes research was provided through independent educational grants from
Abbott Laboratories, Amgen Inc. / Wyeth Pharmaceuticals, Bristol-Myers Squibb, Centocor, Inc., Genentech, Inc. and Biogen Idec, Inc.

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 – CMS-1500 Medical Claims (history from September 1999) – completed for patients
seen in physician offices. More than one billion claims per year submitted by over
870,000 clinicians. These data are available in near real-time and represent the largest
ongoing tracking program of office visit data. These data also track the use of injectable
therapy in the physician office.
– NCPDP Prescription Claims (history from April 2001) – submitted for patients receiving
a prescription via retail pharmacy. The NCPDP prescription claims represent dispensed
prescriptions for approximately 55% of all pharmacies.
• Data includes claims across all third-party payer types, including commercial,
Medicare, Medicaid, and Blue Cross/Blue Shield.
• Most data are updated daily (hospital claims are updated weekly).
 ethods: Test Group Matching (Attended RAPID
M
CME Activity)
• S
 tart with 6,000+ RAPID 2007 CME activity participants (Pri-Med, PCN, Epocrates,
newsletters) and their individual date of activity participation
• Match them with administrative health care claims data (data from 870,000 clinicians)
• Ensure sufficient volume and consistency in the claims to analyze
• Result: 531 clinicians who had sufficient ICD-9 codes 4 months pre/4 months post CME
Definitions
• N
 umber of patients: Number of unique patients with the RA ICD-9 codes during time
period (either 4 months prior to, or 4 months after the CME activity date)
• N
 umber of rheumatologist “referrals”: Number of unique patients with the RA ICD-9
codes who had a claim from a rheumatologist in the time period (either 4 months prior to,
or 4 months after the CME activity date)
• “Referral” rate: Number of “referrals” divided by number of patients, multiplied by 100
Results: Test Group vs Control Group “Referral” Rates
4 Months Pre vs 4 Months Post CME Activity Date

Difference = +4.4%
50 11.8% increase in “referral” rate Pre
41.8 Post
40 37.4
“Referral” Rate (%)

30
Patients with Difference = -0.1%
Patients with
RA = 1,171 18.1 18.0
20 RA = 1,183
Visits to
Visits to Patients with Patients with
rheum = 490
10 rheum = 443 RA = 1,517 RA = 1,575
Visits to Visits to
rheum = 275 rheum = 283
0
Test Group Control Group
Matched data from 531 RAPID 2007 CME activity physician participants.

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 Methods: Control Group Matching (Did not attend RAPID
CME activity)
• F
 or each test group physician, 30 randomly selected control group clinicians were identified
based on:
– Specialty
– State
– Urban/rural location
– High/low average monthly claim volume
• Data from 30 was averaged together for the final results (normalizes data from outlier clinicians)
Conclusions/Recommendations
• P
 ilot results suggest that physician participation in a RAPID CME activity may have a
positive effect on physician performance: an increased rate of visits to rheumatologists
for their patients with RA (referrals)
• Further use of medical claims data is recommended:
– For performance gap analysis (needs assessment)
– To identify clinicians with the greatest need for performance improvement and who
are in the best position to influence patient care (for recruitment)
– For more rigorous educational outcomes measurement
Future Studies/Analysis
• Selection criteria
870,000 Clinicians
– Primary care provider
– 8/14 months of accessible data
– High concentration of female patients, ages 25–55
– High concentration of male patients, ages 50–55
– Fewer than 7 RA Dx over last 14 months
– Least number of patients being comanaged by
a specialist
• Focus of analysis
– Increase in provisional and confirmed diagnosis of RA
amongst this subset of patients
– Increase in referral rate amongst learners vs control group

The current RAPID initiative includes the application of the

claims data and has evolved to a point where we can identify
and recruit the clinicians who are in need of the education and
who are in the best position to impact patient care because
61,382 Clinicians
they provide care for the highest percentage of patients at
(Clinicians care for 17,748,309
high-risk for RA, combined with the fact that these same patients at higher risk of RA)
clinicians have made the fewest diagnoses of RA.

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