ahrq's annual research conference panel session september 16, 2009 1 medication management...

AHRQ's Annual Research Conference Panel Session September 16, 2009 1

Medication Management Measures:

NQF and Beyond

Harold Alan Pincus, MDHarold Alan Pincus, MDProfessor and Vice Chair, Department of PsychiatryProfessor and Vice Chair, Department of Psychiatry

Associate Director, Irving Institute for Clinical and Translational ResearchAssociate Director, Irving Institute for Clinical and Translational ResearchColumbia UniversityColumbia University

Director of Quality and Outcomes ResearchDirector of Quality and Outcomes ResearchNewYork-Presbyterian HospitalNewYork-Presbyterian Hospital

Senior Scientist, RAND CorporationSenior Scientist, RAND Corporation


Medication Management Measures: NQF and Beyond

• Background/Context• NQF Process• Steering Committee Consensus

–conclusions–concerns

• Issues/Questions in Measuring Medication Management Quality


Linking Policy, Practice and Research

Practice Policy

Research


Policy Context• Rising costs

proportion of GDP

• Disparities in care– regional, populations

• Growth in HIT– stimulus, “meaningful use”, RHIO’s

• Translational science– T1, T2, T3, T4/CER

• Alphabet soup of managers/regulators– NCQA, NQF, Joint Commission, PBM, PQRI, NICE

• Quality and safety problems– Crossing the Quality Chasm/IOM

• Health care reform?


To Err Is Human: Building A Safer Health System

First Report

Committee on

Quality of Health Care

in America

To order: http://www.nap.edu

http://www.nap.edu/

http://www.nap.edu/


Crossing the Quality Chasm

“Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized”

The American health care delivery system is in need of fundamental change. The current care systems cannot do the job. Trying harder will not work:Changing systems of care will!


Image: Institute of Medicine Quality Chasm Series


““Crossing the Quality Chasm”Crossing the Quality Chasm”Image: “Crossing the Quality

Chasm”


Preparing for the Future

Standardize Practice Elements– Clinical assessment– Interventions– IT infrastructure

Develop Guidelines– Evidence-based medicine– Shared decision making

Measure Performance– For each “6P” level– Across silos

Improve Performance– Learn– Reward

Strengthen Evidence Base– Evaluate effective strategies– Translate from bench to

bedside to community

Consumer ParticipationConsumer Participation

Leadership Leadership SupportSupport

Clinical Clinical PerspectivesPerspectives

Integrative ProcessesIntegrative Processes


Measure Performance

• “You can’t improve what you don’t measure”• Develop quality metrics

- structure- process- outcomes

• Across silos of data sources– MCO/MBHO/PBM– claims/EHR, etc.

• At each “P” level


““6 P” Conceptual Framework6 P” Conceptual Framework• Enhance self-management/participation• Link with community resources• Evaluate preferences and change behaviors

• Improve knowledge/skills• Provide decision support• Link to specialty expertise and change behaviors

• Establish chronic care model and reorganize practice• Link with improved information systems• Adapt to varying organizational contexts

• Enhance monitoring capacity for quality/outliers• Develop provider/system incentives• Link with improved information systems

• Educate regarding importance/impact of depression • Develop plan incentives/monitoring capacity• Use quality/value measures in purchasing decisions

• Engage community stakeholders; adapt models to local needs• Develop community capacities• Increase demand for quality care enhance policy advocacy

Patient/Consumer

Practice/Delivery Systems

Purchasers (Public/Private)

Populations and Policies

Providers

Plans

Organizational Chart: “6P” Conceptual Framework


Strategies for Influencing Quality of Medication Care

• Guidelines/”Black Boxes”• Provider Training/Education/CME• Academic Detailing• Pharmacist-based Interventions• Preferred lists/Prior auth/Second opinion• Certification/Accreditation/Licensure• Provider Reminder System/Decision Support• Patient Education/Reminders• Quality Measurement/Improvement• Public Reporting/Profiling/Feedback• Financial Incentives/P4P


Medication Management

• 81% of adults take at least 1 med• 90% of Medicare beneficiaries report taking

prescription meds (nearly half use 5 or more)• Between 14 and 23% of elderly receive

inappropriate meds• Up to 40% of patients do not take meds as

prescribed• Adverse drug events 2.5% of ER visits for

unintentional injuries


NQF Process• Open call for measures• Augmented by lit review/National Quality Measures

Clearinghouse• Conditions for consideration

– public domain or IP agreement– responsible entity to maintain– public reporting and QI– complete info (provisional if not tested)

• Criteria for evaluation- PH/Improvement1. importance- PH and improvement2. scientific acceptability-reliable/valid3. useability- decision making/6P’s4. feasibility- data available/burden

• Steering Committee- open consensus/interactive• Member and public comment


Steering Committee Consensus

• Other NQF projects include medication management measures• 35 submitted measures were considered• Measure categories:

– prescribing/selection– dispensing/adherence– monitoring– outcomes

• 19 measures recommended (7 time limited)• 3 measures combined with other submitted measures• Considerable interaction with measure developers to

improve/modify measures• Range of clinical topics spanned CAD, asthma, schizophrenia,

COPD, INR monitoring, generic adherence/monitoring


Recommended MeasuresRecommended MeasuresAdherence Measures- General

Proportion of Days Covered (PDC): 5 Rates by Therapeutic Category

Adherence to Chronic Medications

Adherence Measures- Coronary Artery Disease

Coronary Artery Disease and Medication Possession Ration for Statin Therapy

AND

Coronary Artery Disease and Lipid-Lowering Therapy

Treatment of Coronary Artery Disease (CAD): Ace Inhibitor/Angiotensin Receptor Blocker use

Adherence Measures- Diabetes

Lipid-Lowering drugs for Diabetic Beneficiaries

Diabetes Mellitus and Medication Possession Ration (MPR) for Chronic Medications

Diabetes Suboptimal Treatment Regimen (SUB)

Chronic Kidney Disease, Diabetes Mellitus, Hypertension and ACEI/ERB Therapy

Adherence Measures- Schizophrenia

Schizophrenia: Adherence to Antipsychotics

AND

Schizophrenia: Treatment with Antipsychotics


Recommended Measures Recommended Measures (cont’d)(cont’d)

Asthma Control

Suboptimal Asthma Control (SAC)

Absence of Controller Therapy (ACT)

COPD Management

Pharmacotherapy Management of COPD Exacerbation (PCE): Two rates are reported.

Management of Antipsychotic Medication Use

Patients Discharged on Multiple Antipsychotic Medications

Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

Post Discharge Continuing Care Plan Created

Post Discharge Continuing Care Plan Transmitted to Next Level of Care Provider upon Discharge

INR Monitoring

Monthly INR Monitoring for Beneficiaries on Warfarin

INR for Beneficiaries Taking Warfarin and Interacting Anti-Infective Medications

Medication Management- General

Care for Older Adults- Medication Review (COA)

Medication Reconciliation Post-Discharge (MPR) (NCQA)


Steering Committee ConcernsSteering Committee Concerns

• Submitted (and recommended) measures do not Submitted (and recommended) measures do not represent full array needed to assess/improve qualityrepresent full array needed to assess/improve quality

• Measures not linked or harmonized across multiple Measures not linked or harmonized across multiple developersdevelopers

• Single prescription for chronic diseasesSingle prescription for chronic diseases• Multiple, conflicting, confusing ways to measure similar Multiple, conflicting, confusing ways to measure similar

concepts (i.e. adherence)concepts (i.e. adherence)• Limited testing of measuresLimited testing of measures• Need for continual updatingNeed for continual updating• Significant R and D needed for measures Significant R and D needed for measures

addressed/linked to outcomes, are patient-centered and addressed/linked to outcomes, are patient-centered and cover a broader array of conditions, settings, populationscover a broader array of conditions, settings, populations


Proposed Standard Specifications Proposed Standard Specifications for Adherence Measurementfor Adherence Measurement

Numerator Denominator

1. New Users: For patients with no prescription in the 180 days prior to the measurement period, sum of:

1. New Users: Number of days from the first prescription to the end of measurement period.

Days’ supply of all medications

from the first prescription until the

end of the measurement period.

2. Continuous users: Number of days from the beginning to the end of the measurement period.

**Remove the days’ supply that extend past the end of the measurement period.

**Multiply by 100- cannot exceed 100%

2. Continuous users: For patients with 1 or more prescriptions in the 180 days prior to the measurement period, sum of:

Days’ supply of all medications in

the measurement period

**Remove the days supply that extends past the end of the measurement period and add days supply from the previous period that apply to the current period.


Research Recommendations

• Adherence Measures– appropriate use/reasons for non-adherence

• Plan of care measures– expand patient/caregiver communication

• Medication review/reconciliation– content/accountability

• COPD management– lower risk patients

• Outpatient psychiatry– adherence/monitoring/polypharmacy

• Migraine• Use of technology

– bar coding/decision support/dose calc.• Medication validation

– steps from order to patient/monitoring over time


Issues in Measuring Medication Management Quality

• Measurement v. Improvement• Information lag/real time v. delayed• Use of measures- POC v. external• Accountability- pt/prescriber/pharmacist/plan• Patient-centered measures- $/values/preferences• Clinical exceptions v. “cookie cutter” medicine• Adequacy of data bases

– include Dx/Indication on Rx• Does measurement lead to improvement?

– MH HEDIS• Does improvement lead to enhanced health status?

– Diabetes and ACCORD


The State of Health Care Quality 2006, NCQA

There are, however, disturbing exceptions to this pattern of [overall health care quality] improvement. The quality of care for Americans with mental health problems remains as poor today as it was several years ago. Patients on antidepressant medication are about as likely to receive appropriate care today as they were in 1999.

http://www.ncqa.org

http://www.ncqa.org/

http://www.ncqa.org/


Antidepressant Medication Management: Optimal Practitioner Contacts

Trends, 1998-2005

100%

80%

60%

40%

20%

0%‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05

Commercial

Medicaid

Medicare


Antidepressant Medication Management: Effective Continuation Phase Treatment

Trends, 1998-2005

100%

80%

60%

40%

20%

0%‘98 ‘99 ‘00 ‘01 ‘02 ‘03 ‘04 ‘05

Commercial

Medicaid

Medicare


““Crossing the Quality Chasm”Crossing the Quality Chasm”Image: “Crossing the Quality

Chasm”


Image: San Francisco Bay Bridge

ahrq's annual research conference panel session september 16, 2009 1 medication management...

Documents

quality of health care

quality chasmpreparing

quality chasmimage

systems of care

quality chasmquality

ways care

current care systems

irving institute