BETHESDA, MD 15 October 2009—Eighteen national consensus standards for measuring and publicly reporting on the performance of health care providers in managing medications received the endorsement of the National Quality Foundation (NQF) in August.
The standards-setting organization, widely known for its list of so-called never events, stated that the new measures focus on medication regimens that treat conditions in which nonadherence occurs commonly and results in severe adverse outcomes (see sidebar).
Selected Medication Management Measuresa
Medication possession ratios (MPRs) for chronic medications MPR for statin by patients with coronary artery disease MPRs for antipsychotic-drug regimens by patients with schizophrenia MPR for angiotensin-converting-enzyme inhibitor or angiotensin-receptor blocker by patients with chronic kidney disease or with diabetes and hypertension Percentage of patients with persistent asthma who received more than five canisters of short-acting inhaled beta2-agonist in three months Percentage of patients who had medication review at least once in year Percentage of patients discharged from hospital whose medications were reconciled within 30 days Average percentage of monthly intervals in which patients receiving warfarin did not undergo test to determine International Normalized Ratio Percentage of patients discharged from inpatient psychiatric setting with a continuing care plan
aFrom documents at www.qualityforum.org. Some measures specify patients’ ages.
"These measures," NQF President Janet Corrigan said in a news release, "are a starting point to improve quality and lay the groundwork for additional measure development for continued improvement in medication management."
One of the stated objectives of the consensus-development project was to identify measures that address the quality of medication management provided by Medicare Part D plans, health plans, clinicians, and pharmacists.
The Centers for Medicare and Medi-caid Services (CMS) provided primary support for the project.
But NQF, said Jannet Carmichael, one of several pharmacists on the project’s steering committee, allows organizations in addition to the financial supporter to submit measures for endorsement.
The result is that NQF endorsed medication management measures from four organizations: CMS, seven measures; Health Benchmarks Inc., two measures; the Joint Commission, three measures; and the National Committee for Quality Assurance, six measures.
Carmichael expressed disappointment that the steering committee developed measures with information that would be available in large prescription claims databases.
"The type of measurements that came out of this committee . . . lend themselves more to large data warehouses of prescriptions that don’t have a lot of laboratory [data], don’t have a lot of anything other than the demographics of the patient and the prescription information," she said.
As a result, she said, the measures are more about process and patients’ adherence than clinical outcomes.
Carmichael is pharmacy executive of the Veterans Affairs (VA) Sierra Pacific Network, also known as Veterans Integrated Service Network 21, serving veterans living in northern Nevada, northern California, Hawaii, the Philippines, and Guam.
At VA facilities, she said for illustration, pharmacists and other clinicians have access to blood-pressure measurements and can find out whether someone’s blood pressure is under control—a measure of quality—irrespective of how the person actually takes the medications.
"However, you have to start somewhere," she said of the 18 measures.
Eight of the measures received what NQF called time-limited endorsement, meaning they must pass a field test by a certain date.
Mary Andrawis, ASHP director of clinical guidelines and quality improvement, said the Society, a member of NQF, submitted comments on a draft of the measures.
Even though ASHP approved all the measures, she said, the Society urged NQF to recognize that it needs to fill a lot of gaps.
In focusing on the outpatient setting and prescription claims, Andrawis said, the measures fail to assess the outcomes of many of the medication management services provided by pharmacists, especially those in the inpatient setting.
"Their impact on care is not being appreciated because the [relevant] measures are not there," she said.
The NQF-endorsed measures, for example, say nothing about medication dosages being appropriate and adequate.
Andrawis said CMS asked for measures that would assess decision-making, appropriate use, monitoring, safety, and outcomes of therapy. A specific care setting was not mentioned, she said.
"Even if these were measures just for outpatient use," Andrawis said, "they’re still inadequate . . . [and] they don’t cover all areas of the medication-use system in the outpatient setting."
Carmichael said another NQF-convened group is looking at more-complex measures that may be more applicable to specific patient and pharmacy concerns.
Those measures, she explained, are based on so-called ambulatory administratively enriched data, which include such information as test results and diagnoses.
Another problem with measures based on prescription claims data is a recent one.
Patients who use the $4 prescription program offered by many pharmacies obtain medications without presenting an insurance card, Carmichael said. Those transactions do not generate prescription claims.
Further, she noted, there is no universal health record that really contains all of a patient’s health records.
Carmichael encouraged pharmacists to examine measures beyond the 18 recently endorsed ones.
"There are dozens and dozens of these," she said. "You’re going to have to sift through them and figure out which ones apply to your facility, your institution, [and] what data sets you have in order to measure them.
"And, quite frankly, you might be able to do them better because you actually might have that enriched database."
