Mini-Practice Audit Model (mPAM): Facilitating the CRA RA Guideline Implementation

Objectives Rheumatoid arthritis (RA) affects 1% of the Canadian population and is associated with considerable morbidity and increased mortality. Recently an update to the RA guidelines was published by the Canadian Rheumatology Association (CRA) and the Cochrane MSK group. Research into guideline implementation demonstrates that successful uptake is facilitated by practice audits, self-assessments, enabling educational tools and informed continuing professional development (CPD). The goal of our project was to create and evaluate the implementation of a mPAM based education framework designed to increase uptake of the current rheumatoid arthritis (RA) guidelines. Use of the mPAM framework will enable rheumatologists to identify areas of knowledge and care gaps, as well as enablers and barriers to the practical application of the RA guidelines. Methods An online survey based on the current RA guidelines was distributed to assay knowledge, attitudes and behaviors and inform a modified mPAM. This mPAM was distributed to CRA participants. Participants completed the mPAM and the results were analyzed using descriptive statistics and thematic analysis. Specific domains targeted included patient descriptors, specialist’s practice performance, and participant’s reflections. Results Survey Results: Overall, participants believed in the use of guidelines in clinical practice. However, knowledge and application of the current RA guidelines was varied. Patient Descriptors: Of the charts analyzed using the mPAM, 60% of patients are currently in remission for RA over a range from 1 to 10 years. Of those patients in remission, 69% are receiving conventional synthetic DMARDs (csDMARDs), 23% are receiving biologic or targeted synthetic DMARDs (advanced therapies) and 8% other treatments. Of those not in remission, 57% are receiving csDMARDs, 0% advanced therapies and 43% are receiving other treatments. Specialist’s Practice Performance: Gaps in RA guideline applications were identified in the following areas: discussion of tapering (45%), discussion of possible flare-ups (38%), shared decision regarding management of flare-ups (38%), and medication use (23%). Participant’ Reflections: Thematic analysis elucidated the following: inconsistent documentation, lack of detail of medication, instructions, and shared decision making. importance of frequent chart reviews, and identification of guideline gaps. Conclusion Use of the mPAM allowed gaps to be recognized in the clinical application and documentation of the CRA RA guidelines. Participants noted that the mPAM allowed them to identify gaps in clinical practice and assay ways to address these to positively impact patient care.