Report of the PQA Quality Metrics Workgroup

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Report of the PQA Quality Metrics Workgroup

• Co-Chairs
• Lawrence Brown, PharmD, PhD
• Associate Professor, University of Tennessee
• (Representing the American Pharmacists
  Association)
• Brad Tice, PharmD
• Chief Clinical Officer
• PharmMD Solutions, LLC

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PQA Charge to the Quality Metrics Cluster Groups

• Charge
• Create up to three measure concepts that are
  evidence-based, consistent with the PQA mission,
  and are measures that a pharmacist or pharmacy
  can be able to impact on a consistent basis.

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Cluster Group Objectives

• Objective 1a measures that are based on Rx
  claims data only.
• Objective 1b measures that are based on Rx
  claims data, with medical data available,
  including diagnosis.
• Objective 1c measures that are based on Rx
  claims data, with medical and lab data available.
• Objective 1d measures that are based on
  self-reported data, or data from proprietary data
  bases that are aggregated and used for measuring
  performance/quality of MTM services.
• Objective 2 For each new metric, specify whether
  pharmacists have a direct impact, an indirect
  impact, or both, and provide an example of how
  the pharmacist/pharmacy can impact the metric.
• Objective 3 For each previously approved and
  validated metric, specify whether pharmacists
  have a direct impact, an indirect impact, or
  both, and provide an example of how the
  pharmacist/pharmacy can impact the metric.

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Cluster Group Timeline

• Cluster Groups began to assemble and meet
  telephonically in April 2008
• Calls continued through May and into this week.
• Cluster Group Co-Chairs have had two calls one
  an orientation call, one call to touch base
  after they were underway to share lessons
  learned, and to cultivate some
  cross-communications
• Expect each group to have had between 6-9 calls
  prior to the November 21st live PQA membership
  meeting, with the goal of having new measure
  concepts presented to the LIVE membership in key
  areas by November 21st.

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2008 Cluster Groups

• Cardiovascular
• Consumer Feedback Assessment (renamed from the
  Patient Satisfaction Cluster)
• Cost-of-Care (100 re-focused, re-named from
  Generic Efficiency)
• Diabetes
• Long Tern Care Continuum
• Medication Adherence
• Medication Reconciliation (NEW)
• Mental Health (NEW)
• MTM Services (broken off from the Patient Safety
  Cluster Group)
• Patient Safety
• Prevention Wellness (NEW)
• Respiratory Disorders

Nothing to report at this time
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Questions and Discussion

• Are the cluster groups on the right track?
• Any measures concepts that are missing?
• Are there any obstacles that the cluster groups
  have not identified?

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Cardiovascular Cluster Group ObjectivesCo-chaired
by Heather Rickertsen, Miller Purcell Inc.
Steve Kogut, University of Rhode Island

• Review current and create new measure concepts
  pertaining to medication management for
  cardiovascular diseases for key domains
• drug prescribing
• therapeutic monitoring
• wellness and prevention
• safety.
• Further define measure concepts
• elucidation of required data sources
• assessing the feasibility of measurement
• describing the impact of the pharmacist (i.e.
  direct or indirect).

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CVD- Measurement Concepts for Consideration

• Rates of aspirin and anti-platelet therapies in
  CAD
• Rates of beta-blockers and ACEI/ARB in CAD/HF
• Rates of drugs for dyslipidemia and hypertension
  management
• INR testing and INR within therapeutic range
• Lipid testing and therapeutic goal achieved ( for
  LDL)
• Avoidance of use of thiazolidinedione drugs and
  chronic NSAIDs in HF
• Avoidance of use of short acting nifedipine

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CVD -Potential Obstacles to Developing Solid
Measures

• Most measure will require medical record data or
  other data sources beyond claims.
• The pharmacists impact on these measurement
  areas is likely to be indirect, yet the
  pharmacist may have a more direct role in
  specialized settings (e.g. clinics).
• The measurement topics currently being explored
  may not be entirely attributable to pharmacy
  services, as the role of physicians will often be
  of greater influence on drug prescribing and
  laboratory monitoring tests.

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Cost-of-Care Cluster Group ObjectivesCo-chaired
by Karen Rascati, University of Texas

• The cost-of-care cluster group will develop a
  guidance document for estimating the costs
  associated with Medication Therapy Management
  (MTM) programs.
• This document will offer guidance on two areas of
  cost-estimation
• Costs to the provider for delivering MTM services
• Health care costs that are impacted by the
  provision of MTM services (e.g., cost-benefit or
  cost-effectiveness of MTM).

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Diabetes Cluster Group Objectives Co-Chaired by
David Medvedeff, Avatar Holly Devine,
University of Kentucky

• Review currently approved measures and identify
  if pharmacists/pharmacies have a direct or
  indirect impact
• Articulate methods by which measure is impacted
  (direct counseling, mail campaign, etc)
• Identify, structure and propose new measures with
  broader access to data sources
• Medical claims, labs, proprietary data,
  self-report, etc.

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Diabetes-Expected Outcomes

• Measure-concept(s) consistent with HEDIS quality
  of care for diabetes
• Potentially focus on the process of care (is
  there a claim for an HbA1c or eye exam) versus
  the outcome
• Measure-concept(s) for medication safety
• Drug/disease interactions with oral hypoglycemic
  medications
• Measure-concept(s) for patient ed./counseling
• pharmacist education of sx/sx hypoglycemia, or
  treatment given a prescription for insulin

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Diabetes - Potential Obstacles

• Concerns over pharmacists/pharmacies having
  direct impact on measure
• e.g. if measure was to obtain A1c goal lt9.5 as
  per HEDIS guidelines, how much impact is pharmacy
  vs. other aspects of the local health care system
  
• Idea that pharmacist/pharmacy quality and value
  relate to patient education/counseling
• No SOPs and broadly used data standards to
  capture this level of service

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Long Term Care Cluster Group ObjectivesCo-Chaired
by Albert Barber, Golden Living Clinical
Services Thomas Clark, American Society of
Consultant Pharmacists

• Medication Availability
• Medication Errors
• Medication Outcomes (positive and negative)
• Infectious Disease Prevention and Control
• Customer Satisfaction

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LTC Outcomes

• Develop one or more pharmacy/pharmacist quality
  measures appropriate for the long-term care
  continuum
• Work closely with other cluster groups,
  especially Patient Safety, MTM, and Medication
  Reconciliation to include LTC subset in data
  testing and analysis

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LTC Potential Obstacles

• Unique aspects of individual settings in LTC
  continuumnursing home, assisted living, etc.
• Need data beyond Rx claims data to develop
  meaningful measures
• MTM versus drug regimen review
• Variable role of patient and/or family member as
  customer in long-term care
• Multiple customers in LTC administrator,
  director of nursing, medical director, etc.
• Lack of integrated medical records, especially
  lab data

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Medication Adherence ObjectivesCo-Chaired by
Drs. Jack Fincham, University of Georgia David
Nau, University of Kentucky

• Serve as a resource for clinically-oriented
  cluster groups that develop/revise adherence
  measures
• Mental health
• Diabetes
• Cardiovascular
• Respiratory
• Identify the need for adherence measures for
  other therapeutic areas, and develop measures for
  high-priority areas

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ADHERENCE Therapeutic areas being considered for
adherence measures

• Mental health (antidepressants, antipsychotics)
• HIV / AIDS
• Osteoporosis
• Epilepsy
• Attention-Deficit Hyperactivity Disorder (ADHD)
• Cancer (oral agents)
• Over-active bladder

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Medication Reconciliation Cluster Group
ObjectivesCo-chaired by Todd Barrett, Covenant
Pharmacy MaryAnn Kliethermes, Chicago College
of Pharmacy, Midwestern University

• Conduct an environmental scan to determine if
  performance measures exist for in the area of
  medication reconciliation and if there are
  differences in the medication reconciliation
  process within different care settings.
• Determine how pharmacists/pharmacies fit in the
  overall process, can the role be standardized,
  can measure concepts be identified?
• Develop measure concepts to help healthcare
  practitioners, including pharmacists, apply a
  standardized medication reconciliation process
  consistently.
• Determine if The Joint Commissions definition of
  transfer of care applies to pharmacists/pharmacies
  , discuss ways in which the pharmacists role for
  transitions of care can be documented
  consistently, and how the performance of
  pharmacists/pharmacies can be measured.

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Medication Reconciliation Cluster Group
Standard process and preliminary measures

• Four universal steps in Medication Reconciliation
• Verify collect a current medications list
• Clarify assure medications, doses, directions
  are accurate
• Reconcile compare new meds with list document
  changes
• Transmit communicate changed list to patient
  health providers
• Preliminary Measure Concepts
• Process
• At every level of care or setting there exists a
  patient specific medication list. If it does not
  exist a list is created
• At every transition of care the med list travels
  with the patient
• At each pharmacist-patient encounter the list is
  reviewed and reconciled as needed
• of med discrepancies resolved/ med
  discrepancies identified
• Outcome
• of med errors due to med rec problems/of med
  errors

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Medication Reconciliation Cluster Group
Barriers identified

• Availability of data
• Ability to collect and consolidate data
• Access to data at organizational level or higher
• Translation of data
• Not well defined terminology i.e. transitions of
  care
• Lack of well defined components and processes in
  particular between practice settings
• Technology issues
• Use of free text in medication lists vs. accepted
  codes
• Lack of communication systems between software
• Lack of technology resources for data collection
  of measures
• Liability in that reporting errors currently is
  risky
• Correlation between patient outcomes and
  medication reconciliation

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Mental Health Cluster Group Objectives
Co-chaired by Carol Alter, The TEN Project
Jason Carter, Tennessee Department of Mental
Health
Objectives for 2008 - 2009

• Working principle to guide this group Review
  existing quality measures in the area of mental
  health, specifically focusing on major depressive
  disorder, acute depression, schizophrenia, and
  bipolar disorder and work to create new metrics
  that a pharmacist could have either a direct or
  indirect effect upon.

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Mental Health -Exploration of Potential
Measures

• Examining applicability of HEDIS and other
  measures for major depressive disorder
• Exploring potential measures in the areas of
• adherence
• for major depression schizophrenia
• gap in therapy
• for major depression schizophrenia

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Mental Health - Potential Obstacles

• Not having access to diagnosis presents some
  problems.
• In the Mental Health field there is considerable
  concern about confidentiality, how and what
  clinical information is shared can be a concern.

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MTM Services ObjectivesCo-Chaired by Julie
Kuhle, Iowa Foundation for Medical Care James
Nash, HumanaStaff Liasion Anne Burns, American
Pharmacists Association
Objectives for 2008 - 2009

• Review and revise two measure concepts developed
  by 2006 Patient Safety Cluster Group
• Develop performance measure concepts for MTM
  services including a consistent mechanism to
  document information that will provide a data
  source for the measures.

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MTM Services Expected Outcomes

• MTM Cluster Group will
• propose 2-3 viable MTM measures for further
  specification and testing
• recommend several outcome measures to be
  considered in subsequent years

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MTM Services Potential Obstacles

• Variation in types of services defined as MTM
• Lack of single, consistent data collection
  mechanism
• Variation in how/where MTM services are provided
• Low sample size within individual pharmacies

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Patient Safety Cluster Group ObjectivesCo-chaired
by Neil MacKinnon, Dalhousie University
Diane Cousins, United State Pharmacopeia

• Access to complete medication history at the time
  of dispensing
• To determine how to develop a measure or
  encourage/incent the sharing of relevant
  medication-related information/medication history
  (and other relevant patient health information)
  across pharmacies and other healthcare
  professionals. Medication management, and
  medication prescribing will both improve when
  clinicians have more information available and
  when effective electronic exchange supports this
  process.
• To review resources (e.g., literature, tools,
  etc.) to identify potential new areas of
  measurement not covered by other cluster groups.
  These measures should focus on promoting safer
  patient care.

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Patient Safety Proposed Measures

• 1. Verification of high-alert prescriptions
• Numerator Number of prescriptions with a DUR
  (based on the claims processor's software or
  in-house software) that are properly documented
  with comments following (a) consultation with the
  patient and/or prescriber or (b) assessment by
  the pharmacist.
• Denominator All prescriptions with a DUR (based
  on the claims processor's software or in-house
  software).
• 2. Patient profiles
• Numerator Number of patient profiles containing
  appropriate information regarding a patient's
  disease state(s) when compared to medications
  listed in the patient's drug profile. (Note
  Although information regarding drug allergies and
  previous drug interactions are extremely helpful,
  I am not aware of a mechanism to substantiate
  whether or not a patient was given an opportunity
  to provide this information).
• Denominator All patient profiles.
• 3. Pharmacist conducts a review of patients
  profile on a regular basis
• Numerator Number of contacts
• Denominator Number of reviews completed
• 4. Counseling on high alert drugs - High alert
  drugs to be defined
• Numerator Number of patients taking high alert
  drugs for whom verbal counseling was provided
• Denominator Total number of patients on high
  alert drugs who had a prescription filled at the
  pharmacy

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Patient Safety Proposed Measures

• Other The next four metric concepts may fit best
  under the CAHPS Pharmacy Services Survey rather
  than patient safety we are open to discussion
• 5. When dropping off your prescription, picking
  up or paying for your prescription at the Rx
  counter/ window
• how well does the pharmacy protect your personal
  information from others hearing or seeing it?
  Personal information includes your address, date
  of birth, medications you are taking, pin number
  for your debit card, medications the patient is
  currently on
• 6. When speaking with the pharmacy staff about
  your prescription or health
• how well does the pharmacy protect your personal
  information from others hearing your information?
  Personal information includes your address, date
  of birth, and medications you are taking.
• 7. Crowd control
• Numerator Number of service portals/stations
  allowed to remain open
• Denominator Number of personnel present to
  accommodate each opened service portal
•     
• 7b. Use of Queuing mechanisms (e.g., use of ropes
  for formation of lines)
• Numerator Number of locations that actively use
  queuing for each open service portal.
• Denominator Total number of locations within the
  specified demographic area

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Patient Safety Potential Obstacles

• Documentation, data collection, and sources of
  such data
• Time to review such data
• Data Integration - lack of indication on Rx, etc
• Patient Privacy including
• structural design of the pharmacy
• patient unwilling to divulge private information
• other patients in close proximity

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Wellness Prevention Cluster Group
ObjectivesCo-chaired by Jean Venable Goode,
Virginia Commonwealth University Brian Hille,
Safeway Corporation

• Objective 1 to conduct an environmental scan of
  the marketplace to determine if prevention and
  wellness measures exist in other healthcare
  specialty areas, or with other healthcare
  professionals.
• Objective 2 determine how best to measure the
  performance of a pharmacy or pharmacists, or
  compare pharmacies based on the offerings of
  these services. How would this information be
  collected, documented, and aggregated in a
  consistent and replicate-able fashion?
• Objective 3 determine whether to select a few
  key prevention and wellness services that are
  more widespread and discuss and propose ways that
  the prevalence of the offering of these services
  can be compared, or what other factors can be
  rolled up into the quality of a particular
  wellness or prevention service.

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PQA Wellness and Prevention Cluster Group

• Tentative Measure Concepts
• Smoking Cessation
• Immunization status
• Lipid Management
• Allergy documentation in pharmacy database
• Blood Pressure measurement
• Weight Management
• Asthma Peak flow use
• Diabetes A1c and glucose measurement and
  checking to see if the patient has a blood
  glucose meter
• Others to be determined at next call

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PQA Wellness and Prevention Cluster Group

• Potential Obstacles
• Data source maybe pharmacy patient records
• Difficult to collect
• Pharmacist/Pharmacy will have direct impact on
  measures

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Respiratory Disorders ObjectivesCo-chaired by
Jay Nadas, Walgreens Melissa Fitch, Walgreeens

• To submit and present 2-3 new respiratory
  disorder metrics
• To review previously rejected measures and
  identify ways to refine these measures for
  possible inclusion
• To establish a functional working group that
  allows each member to be an active participant

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Respiratory DisordersMeasure Concepts

• Respiratory disorders under review for 2008
  include the
• following
• Acute bronchitis
• Asthma
• COPD
• Influenza (flu)
• Pneumonia
• Pulmonary Hypertension
• Sinusitis
• Sleep Apnea
• Tuberculosis

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Respiratory Disorders Potential Barriers

• Documentation
• Systems and models are not currently developed to
  document interventions and systematically
  communicate with other healthcare providers,
  allowing for continuity of care that is very much
  needed.
• Patient health record availability
• To make sound clinical decisions where
  performance is being measured, pertinent health
  information should be available.
• Currently, most practicing pharmacists only have
  pharmacy claims data available (i.e.,
  prescription records). The lack of ICD-9 codes,
  lab data, and previous therapies hinder the
  pharmacists ability to impact quality of care.

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Next Steps

• Cluster groups
• Decide on final metrics
• Include description of numerators and
  denominators for each metric
• Include specification of direct or indirect
  impact
• Provide an example of impact
• Determine source of data needed for measurement

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Questions and Discussion

• Are the cluster groups on the right track?
• Any measures concepts that are missing?
• Are there any obstacles that the cluster groups
  have not identified?