Medication Management: Measuring What Matters

Since the publication of the report “Crossing the Quality Chasm” by the Institute of Medicine,¹ hundreds of new healthcare quality measures have been developed at the national, state, health plan, system, and practitioner levels to improve healthcare and promote accountability for better healthcare processes and outcomes.

In the United States, medication-related quality measures are included in various measure sets, including Healthcare Effectiveness Data and Information Set, Electronic Health Record Meaningful Use, accountable care organizations (ACOs), and the Pharmacy Quality Alliance (PQA). Most, however, relate to prescribing processes, adherence rates, or electronic health record capabilities (

Table 1

). While these measures may lead to improved prescribing and adherence, they do not address medication optimization for effectiveness and safety, medication coordination across multiple prescribers and pharmacies, and medication follow-up required between care transitions or office visits.

Beyond the administrative burden, the sheer volume of current measures makes it difficult to identify the right measures for assessing improvement in medication management that encompass appropriate prescribing, effective dosing, avoiding medication interactions and adverse events, and improving adherence. While there has been keen interest in focusing on patient outcome measures (eg, blood pressure or diabetes control), there is still a need for meaningful process measures for medication management and monitoring²—especially in new team-based care delivery models.

Measuring What Matters

Although hundreds of new quality measures exist today, many “care gaps” still do not have measures. One approach to measure development has been to identify measure concepts for “measures that matter.” Some examples are the need for measures that help to:

• Differentiate provider performance: clinical processes, effectiveness, and diagnostic/treatment accuracy
• Identify patient safety improvements and all-cause harm causes
• Close identified gaps in care
• Track care coordination and transitions
• Monitor practice transformation progress
• Define high-performing teams
• Document trusted patient-provider relationships.

There is ample room for a more deliberate prioritization of measure development to close gaps in care that involve medication therapy decision making and management processes. As new care delivery models evolve to focus on value, accountability, and team-based care, many care gaps mentioned above remain unaddressed. These important care gap measures can be more challenging to develop; once developed, consistent measuring that also adjusts for differences in patient populations or practice settings can remain challenging.

US Quality Priorities and Gaps

In 2011, the National Priorities Partnership and more than 50 public- and private-sector organizations worked with the HHS to release the first report from the National Quality Forum (NQF): “2012 NQF Measure Gap Analysis.”³ This NQF report includes 6 priority areas, each with aspirational goals and specific targets around which to focus public- and private-sector performance measurement and improvement: health and well-being, prevention and treatment of leading causes of mortality, person and family-centered care, patient safety, effective communication and care coordination, and affordable care. More work is needed to advance the nation’s measurement capabilities across all priority areas—especially in the gaps identified by the NQF report.

Table 2

outlines some medication management solutions that address these gaps.

Measure development that identifies the extent to which comprehensive medication reviews are implemented at primary care visits and care transitions can address many of the gaps that were identified. When a practitioner conducts a comprehensive medication management review, the patient’s narrative is valued and incorporated into their care planning—including such information as which medications they are actually taking, the impact of medication experiences on healthcare beliefs, the challenges they face with medication access or adverse events, and the outcomes they have experienced.

In addition, we need to measure the extent to which: 1) patients who are at high risk for medication problems are being identified in population health data or referred by healthcare personnel for comprehensive medication reviews; 2) medication optimization recommendations based on evidence-based guidelines are sent to and accepted by prescribers; and 3) culturally and linguistically appropriate patient medication action plans are being developed to address patient self-management goals for effective medication use and safety.

Types of Measures

There are several ways to categorize quality measurement. One way is to look, in combination, at the purpose of measurement, how measures will be used, and who will use them. Measures can be used to: 1) provide information to consumers in public reporting; 2) information for payment (as in pay-for-performance or shared savings programs); 3) compel quality improvement through requirements from an external source; and 4) improve internal quality improvement programs.

Another way to categorize quality measurement is by what is being measured. Donabedian suggests using 3 categories to evaluate medical care, each referring to a component in the provision of patient care: structure, process, and outcomes.⁴

• Structural measures examine the setting in which
• care is provided and whether specific desired components are present. Examples include whether certain qualifications are met (licensing or certification), whether certain technology is available, or whether policies and procedures are defined and used. Such measures utilize specific structural components that have demonstrated improvement in health outcomes in scientific research.
• Process measures are useful when a specific service or action provided to the patient is strongly associated with improving patient outcomes. Measurement of care processes is the most common type of measurement.⁵ Examples include whether a guideline is met or if identified patients receive recommended medication for a specific condition.
• Outcome measures are often the best indicator of the quality of medical care. Outcomes can be as clearly defined as death or survival. Others include clinical end points such as blood pressure measures, patient-related assessment of pain, and patient care experiences. Outcome measures are often more difficult and complicated to measure, and can be influenced by factors not controlled by the healthcare provider. An example of an outcome measure is the 30-day readmission rate following hospital discharge.

Measure Value Sets

We need to ensure that medication-use measures improve care and lead to better outcomes by addressing medication optimization for effectiveness and safety, and coordination across multiple prescribers, sites, and pharmacies. A measure value set is a grouping of measures that together can better assess the value (quality and cost) of care than any single measure can.⁶ Some new approaches to measure set development and usefulness are discussed below.

Families of Measures

One new approach, introduced by the NQF Measure Applications Partnership (MAP),⁷ is “measure families,” groups of measures related to the same condition, patient outcome, or healthcare scenario. The MAP has defined 10 families of measures assessing all parts of the NQF: cancer care, cardiovascular disease, care coordination, diabetes, dual-eligible beneficiaries, hospice care, patient safety, population health, patient- and family-centered care, and affordability. The great majority of existing measures fit into these families and are being used in public or private programs.

Table 3

depicts a family of measures for medication safety (a subset of patient safety).

Families of measures are intended to promote alignment. Increased alignment of performance measures for healthcare delivery may provide substantial benefits, including: 1) increased clarity on the highest priority areas; 2) reduced confusion in interpreting the results of similar, yet slightly different measures; and 3) decreased burden associated with data collection and reporting for various measures addressing similar topics.

Cross-Cutting Measures

Measure families are useful tools for alignment because they can be cross-cutting in nature, with each family including measures that span other families and settings of care. Cross-cutting measures can be used to measure the outcomes of several different conditions, patient-reported therapy outcomes, or patient experiences with the healthcare system.

Table 4

includes cross-cutting measures for care coordination and care effectiveness.

The measures of medication use are applied across conditions and sites of care. For example, a medication selection for care transitions from hospital to home impacts effectiveness and affordability, and improves population health. Medication adherence also impacts effectiveness and affordability, and offers opportunities for person- and family-centered care shared decisions.

Layered Measurement Approach

A layered measurement approach recognizes that different measures are needed for providers, organizations, and external payment and reporting purposes. One set of measures is applied for providers’ internal quality improvement, another related set for internal organization management, and a third related set for public reporting and payment (

Table 5

). Healthcare organizations will eventually be required to report common population-based performance measures, and can choose whichever metrics serve their purposes for internal improvement. For example, hypoglycemiarelated events may be required for care of patients with diabetes, whereas measures of hospitalizations and emergency department visits may be mandated for external accountability and performance requirements.

Developing and Implementing Measures That Matter

The PQA⁸ is a multi-stakeholder, consensus-based measure development organization that collaboratively promotes appropriate medication use and develops strategies for measuring and reporting performance information related to medications. PQA has been developing measures since its inception in 2006, with the most well-known measures being those included in the Medicare Star Ratings program. Data from the Star Ratings program have been used to compare the quality of different health plans. Health plans have begun to collaborate with pharmacies, since pharmacists and pharmacy teams have the ability to influence improvement on the measures.

Since the use of PQA-endorsed measures in the Star Rating program, gradual improvement has occurred in appropriate prescribing and adherence rates.⁹ However, a need still remains to develop medication use measures to address gaps in patient care. As part of the measure development process, PQA continually looks to the future and assesses measurement needs. As the healthcare system and new care delivery models evolve, so do the types of measures that are needed to support team-based care delivery systems and care transitions.

Recently, PQA members approved the first Quality Improvement Indicators (QIIs) for pharmacist-provided medication therapy management (MTM) services to patients recently hospitalized, to address readmissions.¹⁰ The descriptions for these QIIs are: 1) the percentage of high-risk patients who have been discharged from the hospital and who receive MTM from a pharmacist within 7 days; and 2) the percentage of high-risk patients who received MTM from a pharmacist within 7 days post discharge who are readmitted within 30 days of their discharge.

These QIIs are not intended to be performance measures for payment or public reporting. Rather, they are intended to be used by healthcare organizations for internal quality improvement as part of a layered, cross-cutting approach to improve effectiveness of care, affordability (ie, avoid costly readmissions), population health (ie, prevent harm to patients), and patient- and family-centered care (ie, medication reconciliation).

Additionally, one of the PQA work groups¹¹ is currently developing a set of QIIs focused on a team-based approach to identifying patients with hypertension, and then referring for and providing comprehensive medication management (CMM) to achieve blood pressure control. This set of metrics is intended for use by integrated care teams in patient-centered medical homes, ACOs, or community-based health teams that will address structure (referral for CMM), process (provision of CMM), and outcomes (improvement in blood pressure and blood pressure control).

SUMMARY

Most current pharmacy-related measures are medication-related performance and adherence measures. These measures have been adopted by Medicare Part D, quality organizations, health plans, and pharmacies as part of pay-forperformance programs, fulfillment of contractual obligations, plan comparisons, research, and public reporting. However, with the evolution of new healthcare delivery models, there is a need to develop additional quality improvement measures that focus on medication management processes and patient outcomes that can be used by pharmacists, healthcare providers, and quality improvement specialists to implement strategies to better understand the efficiency and outcomes of internal medication management processes.