Kangho Suh, PharmD Candidate

Diabetes mellitus is a metabolic disorder where the body inadequately produces or uses insulin in response to el

diabetes is characterized by the total absence of insulin

production by the pancreas; symptom onset is usually

more apparent and marked by polyuria and polydipsia.

With type 2 diabetes, the body does not produce normal

amounts of insulin and/or does not utilize insulin properly.

Long-term complications resulting from poor glucose

control include retinopathy, neuropathy, nephropathy,

and peripheral artery disease. Therefore, goals of treatment

are to maintain blood sugar concentrations within

normal range, decrease the chance of long- and short-term

complications as well as comorbidity and mortality,

and improve the patient’s overall quality of life.

to the appropriate drug therapy—whether that

be insulin replacement or oral hypoglycemic agents—is

paramount to achieving these goals. The purpose of this

article is to update pharmacists on medical and pharmacy

quality measures for diabetes, and discuss the future

role of pharmacists in the effort to provide quality care

Importance of Quality Improvement for Diabetes

In the United States, diabetes is listed as the number 7 reason for all-cause mortality.

Approximately 10% of people 20 years or older have diabetes, and the disease is estimated to cost about $175 billion annually.

 Because of its significant economic and humanistic impact, diabetes has long been the focus of healthcare improvement efforts. The National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) includes several diabetes quality measures, as does the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI, soon to be renamed Physician Quality Reporting System [PQRS]). The National Quality Forum (NQF), which reviews supporting data on healthcare quality measures, already has endorsed many of these measures for use in health plans and physician quality initiatives.

Appropriate use of medications has become an increasingly important public health issue. About 40% of the elderly population use more than 5 medications,

and between 14% and 23% of those patients get improper medications.

 With more than a million new diabetes diagnoses every year, an estimated 57 million patients in the prediabetes category, and more than two-thirds of diabetic patients requiring at least 1 oral medication,

 pharmacists play an increasingly important role in managing drug therapies for this disease. Studies have demonstrated positive outcomes for diabetic patients who are actively monitored by a pharmacist. These positive outcomes included tighter control of blood sugar as evaluated by glycosylated hemoglobin (A1C) levels, higher influenza vaccination rates, and decreased overall costs.

 Recognizing the value of pharmacists in improving diabetes care, the Pharmacy Quality Alliance (PQA) has established several measures aimed at improving the quality of medication therapy in the community pharmacy setting. These measures were developed with technical support from NCQA and were intended to be based on information gathered from prescription data.

In 1991, NCQA developed HEDIS as a mechanism to evaluate if the quality of care by accredited plans met established quality standards.

 Though plans are held accountable for HEDIS performance, physicians’ and other medical providers’ performances are ultimately the subject of HEDIS quality measurement, with the idea being that plans will improve quality by educating and supporting the providers in their network. Presently, there are 8 diabetes-specific HEDIS measures focused on long-term diabetes control (eg, A1C testing), longterm complications (retinopathy and nephropathy), and cardiovascular comorbidities (hypercholesterolemia and hypertension).

CMS Physician Quality Reporting Initiative

The Centers for Medicare & Medicaid Services implemented the PQRI in response to the 2006 legislation requiring establishment of a quality reporting program for physicians and other eligible healthcare professionals who are Medicare providers.

 These providers may obtain a bonus payment on allowable charges for Medicare services rendered by reporting quality data. For 2010 the incentive payment is 2% of the estimated allowed charges for covered services rendered during the reporting period. In 2011, the incentive payment will decrease to 1% of allowed charges. At present, the bonus incentive is limited to payment for reporting, regardless of performance. Payments have been authorized through 2014, with a payment adjustment beginning in 2015 for providers that do not successfully report on quality measures. The PQRI measure set includes several measures specific to diabetes that were developed 

by NCQA, the American Medical Association—sponsored

Physician Consortium on Performance Improvement, and

the American Podiatric Medical Association (

The Pharmacy Quality Alliance has developed and completed feasibility testing on a total of 15 measures to evaluate and measure medication use—related outcomes. Four of the measure types assess medication therapy for diabetes: (1) gap in therapy, (2) proportion of days covered, (3) excessive doses, and (4) suboptimal treatment of hypertension.

 Within each type are several individual measures pertaining to specific drug classes (eg, proportion of days covered may be measured for sulfonylureas, biguanides, and thiazolidinediones). The Pharmacy Quality Alliance supported 5 phase 1 demonstration projects with the objective of testing the feasibility of implementing these measures and developing a performance-reporting process in the community pharmacy setting. The initial project consisted of 5 different sites that fit into 1 of 3 models. Model 1 was a single health plan, model 2 was a coalition of health plan—pharmacy organization partnerships, and model 3 was a community pharmacy corporation.

How Pharmacy Quality Measures Are Calculated

Articles

The continuing education article reviews diabetes quality improvement efforts and the potential for expanding the role of pharmacists as clinical care providers.