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Objective: To evaluate the American College of Rheumatology (ACR) starter set of quality measures for rheumatoid arthritis (RA) in an actual patient cohort that preceded publication of the quality measures., Methods: We retrospectively applied the 2006 ACR quality criteria to a prospectively studied cohort of 568 patients with RA treated by 1,932 unique physicians including 255 different rheumatologists between the years 1999 and 2003. Data on performance were obtained from self-report surveys and medical record review within 12 months., Results: At least 1 joint examination was performed in 98% of patients. Patient and physician global assessments were reported for 79% and 74% of patients, respectively. A total of 85% of patients received disease-modifying antirheumatic drugs (DMARDs). DMARD adjustments were made for 50% of patients in whom increasing disease activity was noted at least once and for 64% of patients in whom increasing disease activity was noted during 2 (of 4) 3-month periods within the year. Compared with self-report surveys, medical records substantially underreported performance on quality measures., Conclusion: The ACR-endorsed quality measures for RA can be assessed using available data sources. When both self-report and medical record data are used, adherence rates, designed to serve as minimum standards of care, were moderate or high for most measures. Prior to using indicators to compare quality across groups, specific strategies for operationalizing measures and for using accurate data sources to assess adherence to the measures should be defined.

Objective: To construct quality measures with measurement validity and meaning for clinicians., Methods: We conducted a prospective cohort study of rates of change in disease-modifying antirheumatic drug (DMARD) and/or systemic corticosteroid drug or dose for 568 patients with rheumatoid arthritis (RA) across 6,159 clinical encounters within 12 months to examine how changes in clinical specifications change adherence., Results: Rates of DMARD change were sensitive to specifications regarding the intensity of disease activity (severe or moderate), duration of specified disease activity, and length of the observation period. Over 12 months, the proportions of 377 patients with severe disease activity observed for 1-month, 2-month, and 3-month time blocks who had a change in DMARD drug or dose were 36%, 57%, and 74%, respectively. Over 12 months, a change in DMARD drug or dose was observed for 44%, 50%, and 68% of 377 patients with severe disease within 3 months, 6 months, and 12 months, respectively, of the patient meeting criteria for severe disease activity. A change in DMARD drug or dose was observed for 21%, 23%, and 34% of 149 patients with moderate disease activity within 3, 6, and 12 months, respectively, of the patient meeting criteria for moderate disease activity., Conclusion: Rates of pharmacologic interventions for patients with moderate and severe RA disease activity vary substantially by intensity and duration of disease activity and by duration of period for observing change. Lack of precision in explicit process criteria could substantially mislead comparisons of quality of care across comparison groups.

Objective: To evaluate the effectiveness of the Spanish Arthritis Empowerment Program as presented by the Arthritis Foundation, Southern California Chapter, in Orange County, California., Methods: Participants with arthritis (n = 141) enrolled in the program between October 1999 and May 2001. All materials were in Spanish. Written pretest, 6-week posttest, and 6-month followup tests measured pain rating, self-report joint counts, function (modified Health Assessment Questionnaire [mHAQ]), self efficacy, self-care behavior, and arthritis knowledge., Results: Mean age was 51 years, 92% were female, 84% were born in Mexico, 55% had sixth grade education or less, and 60% had no medical insurance. Of the 141 participants, 118 completed 6-month followup testing. Repeated-measures analysis of variance showed significant improvement from pretest to 6-month followup in pain (6.0 versus 3.4); self efficacy (5.5 versus 8.4), self-care behavior (1.7 versus 4.9), arthritis knowledge (1.6 versus 4.5), and general health (2.1 versus 2.5), all at P < 0.001. Small improvement was reported in mHAQ (0.56 versus 0.50; P = 0.024)., Conclusion: The Spanish Arthritis Empowerment Program was successfully disseminated. Significant improvements in self efficacy and in arthritis symptoms were maintained at the 6-month followup.

Objective: To describe beliefs and self-care strategies of American Indians with chronic arthritis joint pain., Method: In-depth interviews were conducted with a convenience sample of urban-dwelling American Indians (n = 56) concerning self-care and beliefs about arthritis; objective measures of arthritis disease activity were obtained through standardized interview protocols., Results: Joint pain was not generally assumed to be arthritis nor directly related to aging. Belief that chronic pain affecting multiple joints was a serious and unexpected condition oriented American Indians' decisions to seek medical attention. However, verbal communications about pain may be subtle or under emphasized. Few coping strategies were used to control either chronic or episodic pain., Conclusions: Chronic arthritis pain may not be optimally managed in this population. Cultural assessment should recognize that American Indian patients may understate serious symptoms. Community educational interventions should target this population to enhance self-care, pain management, and communication of arthritis symptoms to physicians.

Objective: To improve assessment of arthritis joint pain in American Indians by describing how symptoms are communicated., Method: In-depth interviews were conducted with American Indians who experience chronic joint pain (n = 56), to elicit descriptions and self-reported ratings of pain, disability, and beliefs associated with the pain for affected joints (n = 326)., Results: Discrete sets of specific verbal descriptions distinguished inflammatory arthritis (n = 20 terms) from noninflammatory arthritis (n = 22 terms), and indicated levels of pain intensity. An additional set of 14 vague but commonly used verbal descriptors did not distinguish the type of joint disease or pain intensity., Conclusions: Subtle pain complaints and vague verbal descriptions, such as "ache," "hurt," and "discomfort," may reflect severe pain symptoms, disability, and more serious joint disease in American Indian patients. In addition, certain specific sensory descriptions used by American Indians suggest inflammatory arthritis and may warrant further evaluation.