Clinical pharmacists are uniquely positioned to deliver a continuation appropriateness measure that no existing quality framework produces.
The Healthcare Effectiveness Data and Information Set (HEDIS) measures whether a patient received the right drug at initiation. Star Ratings measure whether the patient is still taking it. Nobody measures whether someone has confirmed that the drug is still the right one.
That gap sits in the middle of every clinical pharmacist's caseload. A patient on semaglutide (Wegovy; Novo Nordisk) for 14 months with a plateau in weight loss and no recent hemoglobin A1C test. A patient on adalimumab (Humira; AbbVie) for 3 years when 3 biosimilars are available and nobody has assessed the switch. A patient on a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor in indefinite maintenance with no imaging in 9 months. Every clinical pharmacist has seen these patients. The question is whether anyone is measuring what happens when someone finally looks.
In 2 governance cycles I conducted across 34,500 specialty continuation members, the clinical picture was consistent. A PharmD reviewer opens an assembled case with 4 claims fields plus available laboratory and monitoring data, organized into a structured reassessment prompt. The reviewer sees duration of therapy, dose trajectory, last lab dates, and any gaps in expected monitoring. The clinical question is specific: Does continuation at this dose, for this member, at this point in their trajectory, reflect a deliberate clinical decision—or a default?
The determination takes about 4 minutes per case. Technology handles the data assembly, and the pharmacist makes the call. Four outcomes are available: continue (appropriate), adjust (dose modification indicated), taper (step-down indicated), or switch (alternative indicated). The review is advisory only—no denial authority, no override, no utilization management action. The treating provider keeps full clinical authority, and the pharmacist documents what governance found.
Here is what governance found: Across both cohorts, 58% to 60% of reviewed members had grounds for a trajectory change recommendation.¹ A member on the same glucagon-like peptide-1 receptor agonist dose for 14 months with no measurable response. A biologic patient who was never assessed for a biosimilar that became available 2 years ago. An oncology maintenance patient with no recent imaging to confirm the therapy is still indicated. These are not bad prescribing decisions; they are good prescribing decisions that were never revisited.
And 40% to 42% were confirmed as clinically appropriate, or what the methodology terms the documented appropriateness rate (DAR). A qualified, independent reviewer looked at each of those members and documented that this therapy, at this dose, for this member, is the right call. That finding is as important as the trajectory changes. No prior authorization log, no pharmacy benefit manager (PBM) report, and no claims analysis produces that documentation.
The reviewer in these governance cycles is not a physician making a clinical order. It is a doctor of pharmacy, an advanced practice registered nurse, or a physician’s assistant making a structured clinical assessment under an advisory standard. The skill set required—reading a medication history, interpreting lab trends, assessing dose appropriateness, evaluating therapeutic alternatives—is exactly what clinical pharmacy training produces. The profession that manages specialty formularies is best equipped to assess whether the therapies on those formularies are still effective.
Existing quality frameworks measure the front end of the therapy life cycle: Was the right drug selected? Is the patient taking it? Was monitoring initiated? The back end—the months and years of continuation that follow—has no quality measure. HEDIS does not measure it. Star Ratings do not measure it. No accreditation standard requires it.² The infrastructure to measure it did not exist.
Now it does. The reviewer influence rate (RIR) measures governance yield, which is the percentage of reviewed cases that showed grounds for trajectory change. The DAR measures governance quality as the percentage that were confirmed appropriate. RIR plus DAR always equals 100%. Together, they tell a plan, a board, and a regulator something that no existing metric tells them: Someone looked, and here is what they found.
The quality measurement landscape is moving toward exactly this kind of accountability. Centers for Medicare & Medicaid Services Star Ratings increasingly reward therapy management beyond adherence. State PBM reform legislation, including California's State Bill 41, which imposes explicit fiduciary duties on PBMs, is creating new expectations for how pharmacy benefits are governed over time.3 The Consolidated Appropriations Act of 2026 mandates PBM pricing transparency, which gives plan sponsors visibility into what they spend.⁴ The next question is whether anyone governed what that spending bought.
Joseph Nalley is the founder and CEO of Cadence, LLC, which developed and commercially operates the continuation governance methodology and metrics described in this article. The governance standard specification is publicly available at showyourwork.health.
Published therapeutic inertia literature predicts that the gap is large. A systematic review of 53 studies reported a median time to treatment intensification exceeding 12 months.⁵ US clinical inertia prevalence ranges from 35% to 86%.⁶ For example, adalimumab biosimilar adoption remains in the low single digits nationally despite widespread availability.⁷ When structured reassessment is applied to a continuation population for the first time, the findings are consistent with what the literature predicts, and consistent across therapy classes, payer types, and population sizes.
The metric does not yet exist in any formal quality framework, but it should. And the clinical pharmacists who already manage these formularies are the ones who would deliver it.
