Room for Improvement in a Rheumatology Clinic Protocol Visit Process

From the 2018 HVPAA National Conference

Nathalie E. Chalhoub (University of Cincinnati), Catherine Donnelly (University of Cincinnati), Steven Cogorno (University of Cincinnati), Avis Ware (University of Cincinnati)


Adherence to therapeutic treatment plans can be difficult for patients with chronic diseases such as Rheumatoid Arthritis (RA). Self-management involves taking disease modifying anti-rheumatic drugs (DMARDs) as prescribed, as well as completing lab testing for medication monitoring, which can be burdensome [1].


Prior standard of care in our clinic involved a nurse led ‘protocol visit’ during which a rheumatologic review of systems was performed, and lab testing for each patient included a CBC, CMP, sedimentation rate and CRP. This alternated every 2 months with a doctor led clinic visit.


We instituted a quality improvement project to improve the ‘protocol visit’ process. We aimed to determine patient knowledge of medications, provide education in this area to promote adherence and improve the lab testing algorithm by tailoring to specific medication use.



A standard ‘protocol visit’ template was created in Epic for use by nursing staff, with a focus on patient adherence to medications, lab testing, and documentation of safety testing and vaccinations. We used the five item version of the Compliance Questionnaire for Rheumatology (CQR5), a self-reported adherence measure to identify patients with sub-optimal adherence to DMARDs [2]. Two additional questions were asked; “Is the patient taking the rheumatology medications as prescribed?” and “Is the patient able to state medication name, dose, and frequency (‘teach back’)?”.


A total of 46 RA patients had a protocol visit appointment scheduled between January 8 and March 26, 2018, of whom 6 patients missed their appointment. Mean age was 58 years (± 8) with a female preponderance (80%). The majority reported taking their rheumatology medications as ordered (88%) and 80% were able to ‘teach back’ their medications’ name, dose and frequency as prescribed. A meeting with the clinic nurses to obtain feedback was set at 8 weeks after implementation. The main concern raised was the difficulty for patients with the CQR5, to understand question wording and answer without asking for nurses’ assistance. Data collection to quantify improvement in cost of care with the reduction in lab testing is underway but not yet available.


We found the ‘teach back’ method a helpful tool to assess patients’ knowledge gap in their prescribed rheumatologic medications. This allows for more teaching at both nurse and physician visits to enhance patients’ understanding of their medications. We are unable to assess the utility of the CQR5 questionnaire at this point, as patients answered the questions with nurses’ assistance. Based on the nurses’ subjective feedback, we believe that the patients’ education level might be a factor, so as a next step, patients will answer the CQR5 questions without assistance, knowing that many questions might be left unanswered if not understood. If the CQR5 questionnaire is unhelpful in our patient population, a different self-adherence assessment measure will be sought.

Implications for the Patient

Low adherence in patients with RA may lead to increased costs and disease progression with loss of function and increased disability [3]. By continuing this standardized ‘protocol visit’ process, including the ‘teach back’ method, we hope to continue to improve patient adherence, patient satisfaction and outcomes.

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