SPECIAL FEATURE  Pharmacy accountability

SPECIAL FEATURE

ar Layar

A suite of inpatient and outpatient clinical measures for pharmacy accountability: Recommendations from the Pharmacy Accountability Measures Work Group Mary A. Andrawis and Jannet Carmichael Am J Health-Syst Pharm. 2014; 71:1669-78

T

hree defining characteristics of national healthcare policy that affect patient care are accountability of providers, standardization of performance measures, and incentives for improvement.1 Accountability for outcomes and health status is jointly shared by the patient and provider. Structural changes to the delivery of healthcare services are underway via the development and implementation of accountable care organization and patient-centered medical home models that increasingly place accountability for the quality of patient care on the provider through the use of standardized performance measures and financial incentives. Pharmacists are accountable as part of the patient care team for high-quality patient outcomes and, at a minimum, safe care. Nationally, pharmacists are being called on to deliver on this accountability; 1 of the 34 National Quality Forum’s (NQF’s) Safe Practices for Better

Healthcare asserts that “pharmacy leaders should have an active role on the administrative leadership team that reflects their authority and accountability for medication management systems performance across organizations.”2 Accountability Accountability for the quality and safety of the medication-use process rests on pharmacists who contribute to the patient care team in hospitals and ambulatory care settings. There is sufficient evidence that the contributions of the pharmacist to the patient care team improves clinical outcomes. The results of a meta-analysis of nearly 300 studies, conducted by Chisholm-Burns et al.,3 indicated that pharmacist-provided direct patient care resulted in highquality patient outcomes. In order to reflect the expected accountability of pharmacists in a measurable way, ASHP formed a

Mary A. Andrawis, Pharm.D., M.P.H., is Senior Advisor, Centers for Medicare and Medicaid Innovations, Baltimore, MD. Jannet Carmichael, Pharm.D., FCCP, FAPhA, BCPS, is VISN21 Pharmacy Executive, Veterans Affairs Sierra Pacific Network, Reno, NV. Address correspondence to Dr. Carmichael (jan.carmichael@ va.gov). The contributions of the following individuals are acknowledged: Carol W. Birk, B.S.Pharm., M.S.; Frank Briggs, Pharm.D., M.P.H.; Phil W. Brummond, Pharm.D., M.S.; L. Hayley Burgess, Pharm.D.;

dedicated work group on accountability measures based on recommendations from its Council on Pharmacy Management. In 2010, the council recommended that ASHP “review current quality measures” and suggested that “a good strategy may be to evaluate which of these existing measures most closely reflect the quality of pharmacy services.”4 In 2011, the council “strongly encouraged ASHP to devote resources to developing products that support pharmacy leaders’ efforts to organize and report quality and productivity measures in their institutions.”5 The proceedings from the ASHP Pharmacy Practice Model Summit also solidified the viewpoint that pharmacy leadership should be at the forefront of contributing to accountability of patient outcomes with respect to medication use.6 Pharmacy departments and pharmacists require standardized and validated sets of quality measures

Curtis Collins, Pharm.D., M.S.; Debra Cowan, B.S., Pharm.D.; Patricia C. Kienle, B.S.Pharm., M.P.A., FASHP; Julie Kuhl, B.S.Pharm.; Shekhar Mehta, Pharm.D., M.S.; Steve Riddle, B.S.Pharm., BCPS, FASHP; Philip Schneider, M.S., FASHP, FFIP; Jamie Sinclair, M.S., FASHP; Darren M. Triller, Pharm.D.; and Kristen E. Webb, Pharm.D., M.P.H. The authors have declared no potential conflicts of interest. DOI 10.2146/ajhp140346

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

1669

SPECIAL FEATURE  Pharmacy accountability

and metrics in order to determine specific core pharmacy services that link resource utilization and assess the impact of medication use on patient outcomes.1 ASHP is uniquely positioned to lead the identification and development of these pharmacysensitive quality measure sets to demonstrate the accountability for patient outcomes by health-system pharmacists. Current medication management quality measures endorsed by multistakeholder organizations focus on adherence, are often based on nongranular data sets, and fail to recognize pharmacists’ contribution to and accountability for patient outcomes. Project description ASHP developed the Pharmacy Accountability Measures Work Group to identify measures that establish accountability and demonstrate the value of health-system pharmacists in keeping patients safe and improving outcomes. The goal of the work group was to identify a suite of measures that address preventable harm in the inpatient and outpatient settings (e.g., adverse drug events, drug-related hospital admissions) that can be adopted universally on pharmacy dashboards to reflect pharmacy accountability. Measures were selected based on alignment with the national healthcare agenda and the availability and extent of evidence that pharmacy services can prevent patient harm. The work group conducted an extensive search of quality measures using the NQF’s Quality Positioning System (QPS) as well as the Agency for Healthcare Research and Quality’s (AHRQ’s) National Quality Measure Clearinghouse (NQMC). Many of the selected measures have been previously vetted and endorsed by national measure developers and standard setting organizations, such as the National Committee for Quality Assurance, Joint Commission, Centers for Medicare and Medicaid 1670

Services (CMS), and Pharmacy Quality Alliance. In some instances, the work group did not identify currently endorsed measures that were sufficient, and concepts were created based on directness and importance to measure a particular domain. The work group will use these modified endorsed measures and novel concepts to provide a proactive feedback mechanism to inform measure developers during open comment periods to recommend adjustments to existing and proposed measures. The measures recommended by the work group fall into the following four clinical topics: anticoagulant therapy, glycemic control, antibiotic stewardship, and pain management. Topics and metrics were selected by consensus of the Pharmacy Accountability Measures Work Group. The work group will periodically reassess and identify pharmacy-sensitive measures that align with and track patient outcomes and provide a suite of suggested quality and safety measures annually for review and adoption by the profession. In some cases, modifications to the measures have been suggested that are consistent with evidence-based literature that has been published after a measure’s finalization and endorsement. These selected measures have undergone peer review and a public comment period in which ASHP requested members’ submitted feedback on the potential measures. Many individuals provided a multitude of important suggestions that shed light on the measures’ use in various clinical settings. A second review period is planned for external stakeholders. Since these measures will be reviewed annually, future public review periods will be available so that stakeholders can provide recommendations to the measures list. Appendix A provides a list of these selected pharmacy accountability measures. This list includes specifications and caveats to the measures’ implementation and use for qual-

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

ity improvement within the health system. A list of toolkit resources is provided in Appendix B. This suite of measures is finalized, and health-system pharmacists are encouraged by the work group to adopt these metrics in an effort to contribute to the assessment of the impact of pharmacy. Further, users are encouraged to benchmark results with other healthcare partners and organizations. Relevance The goal of the work group was to identify services that optimize medication use and connect this process to patient outcomes. The work group sought to identify a collection of established quality metrics that show accountability of pharmacists for their services. In identifying these measures, the work group hoped to highlight best practices that have been demonstrated to significantly improve patient outcomes and reduce hospital-acquired conditions and hospital admissions. Process for identifying measures The work group began its work in fall 2011 and conducted a comprehensive search of existing measures that have been endorsed by consensus-building organizations. Preliminary data from the Centers for Disease Control and Prevention (CDC) were used to assess clinical areas that would produce the greatest impact in terms of improving outcomes.7 The work group held periodic meetings beginning in October 2012 via telephone and Web conference. Consensus was reached on four clinical domains: anticoagulant safety, glycemic control, antimicrobial stewardship, and pain management. The work group searched the NQMC maintained by AHRQ as well as the NQF’s QPS. The work group also reviewed the measures under consideration for use in federal programs that were released by CMS in December 2013. In some instances,

SPECIAL FEATURE  Pharmacy accountability

the work group identified currently endorsed measures that were insufficient, and concepts were created to improve measures based on directness and importance. The initial set of measures was divided into inpatient focus and outpatient focus and was disseminated to the ASHP membership for a six-week peer-review period from mid-July 2013 to the end of August 2013. Over 50 comments on the list of measures were obtained from the ASHP membership. ASHP members provided great insight into the real-world use and applicability of the suggested measures. The work group addressed each of these comments using an adjudication process. The adjudication process included discussion within the work group as well as communication with the measure developer to inform them of perceived issues with implementing the measure into workflows and analyzing data. After this review period, some modifications were made to the list of measures to provide comprehensiveness. The measures were then proposed to the ASHP Council on Pharmacy Practice to gain further insight. An annual review process is planned to review new measures and assess the use and currency of the measures in the recommended list. A feedback mechanism to the developers of measures is also planned to provide insight for future revisions of their quality measures. Description of indicators As described above, the measures recommended by the work group fall into four clinical topic areas: anticoagulant safety, glycemic control, pain management, and antimicrobial stewardship. The first three of these domains align with the draft National Action Plan for Adverse Drug Event Prevention.8 Brief descriptions of each of the domains are provided below. In early March 2014, ASHP convened the Ambulatory Care Conference and Summit, and a major goal of the

multistakeholder collaboration was to create recommendations and a framework to evaluate clinical outcomes in ambulatory care settings. At the time of this writing, these ambulatory care recommendations are currently being finalized. These recommendations will be considered when this suite of measures is updated. Anticoagulant safety. Inpatient venous thromboembolism (VTE) prophylaxis programs led by pharmacists contribute to substantial quality improvement and cost reductions in health systems.9 Well-known and validated measures were selected for this domain to ensure patient safety by improving anticoagulation control through bridge therapy (measure VTE-3), reducing potential VTEs with appropriate prophylaxis in hospitalized patients (VTE-6), and educating patients and caregivers about discharge anticoagulation therapy (VTE-5). These measures reflect current evidence on prevention of harm through appropriate management of anticoagulant therapy. For outpatient anticoagulant measures, the work group supports the use of the Rosendaal et al.10 time in therapeutic range (TTR) as a standard method to measure TTR. The TTR has been shown to be an important marker for outcomes of safety and effectiveness of warfarin.11 A companion to measuring the TTR is the requirement for regular laboratory test monitoring of International Normalized Ratio (INR) values with warfarin therapy, which complies with the 2012 American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. 12 As warfarin therapy is influenced by various factors such as concomitant antiinfective medications, this population is at risk for labile INR control. Prompt review of INR values (within three to seven days) after initiation of the interacting antiinfective is a supported measure. This outpatient anticoagulant measure further reinforces maximizing the TTR.

Glycemic control. Inappropriate medication-related management of diabetes creates unnecessary preventable harm.13 Existing endorsed measures only describe adherence to antidiabetic agents and do not directly measure harm from highalert medications. The AHRQ quality indicator, “diabetes mellitus: hospital admission rate for short-term complications,” is broad and does not specifically capture a direct relationship between medication administration and harm from inappropriately managed glycemic agents. Therefore, the work group selected a pair of measures that have been developed by the Florida Medical Quality Assurance Initiative. The measures are the incidence of hypoglycemic events and the incidence of hyperglycemic events and can be used to account for medication safety in the hospital setting. Full specifications of these measures are freely available. For the outpatient setting the work group had concerns about the overuse of hypoglycemic agents resulting in adverse drug events. The American Diabetes Association (ADA) recommends a patient-centered approach to diabetes care and individualizing glycosylated hemoglobin (HbA1c) goals, and the work group stated a threshold of 9% was valuable.14 The work group selected a pair of measures to consistently capture the safety of medication therapy for outpatient diabetic patients. This pair of measures includes a measure of consistent monitoring of HbA1c as well as a measure of poorly controlled diabetes (HbA1c value exceeding 9%). The work group recommends this measure pair as it will accurately capture both monitoring and optimization of effective drug therapy. Pain management. Pharmacists are engaged in patient care settings (e.g., hospice, emergency departments) that require a high degree of pain management.15,16 The work group stated that existing endorsed

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

1671

SPECIAL FEATURE  Pharmacy accountability

measures for pain management do not adequately assess medicationuse safety. Many existing measures are related to diagnostic assessment only. Acetaminophen is the most commonly implicated medication in acute liver failure and causes over 400 deaths in the United States each year.17 The work group provides a single measure of acetaminophen use that is being developed by the Pharmacy Quality Alliance for the ambulatory care setting. A novel measure concerns secondlevel review by a pharmacist or pain specialist. This measure concept has strong implications for appropriate prescribing of narcotic analgesics. This metric may also be adapted for outpatient use if desired. The work group also selected a measure on naloxone reversal for the inpatient setting based on the current efforts within

CMS and the National Quality Strategy to address adverse drug events. Antimicrobial stewardship. Pharmacists play crucial roles in antimicrobial stewardship efforts within the health system.18 The Prophylactic Antibiotic Selection for Surgical Patients (SCIP-Inf-2a) and Prophylactic Antibiotic Discontinued Within 24 Hours After Surgery End Time (SCIP-Inf-3a) measures were recommended by the work group based on their well-known impact on patient outcomes and support from the 2013 Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery, a collaboration among ASHP, the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America, and the Surgical Infection Society.19 Current guidelines for community-acquired pneumonia (CAP) were developed

Figure 1. Framework for revising recommended accountability measures.

by CDC, IDSA, the American Thoracic Society, and the Canadian Infectious Disease Society/Canadian Thoracic Society, who convened and reached a consensus of regimens to target the most common causes of CAP.20 Therefore, the work group included the measure Initial Antibiotic Selection for CAP in Immunocompetent Patients (PN-6). The work group selected the outpatient antimicrobial stewardship measure from the National Committee of Quality Assurance—avoidance of antibiotic treatment in adults with acute bronchitis—due to the overprescribing of antibiotics for predominantly viral (90%) infections and a documented lack of efficacy with azithromycin use.21,22 Process for updating and revising list of measures Annual periodic review is outlined in Figure 1. A major component of the process is the valuable feedback that can be obtained from measure end users to inform the measure developers on the modifications to the specifications based on real-world use. This information can also be used to inform the Department of Health and Human Services on measures being used in pay-for-performance programs. The expert panel members will reconvene each August to assess the scope and integration of existing clinical quality measures in national quality-improvement programs. An environmental scan of implemented measures will help guide consensus on changes that may be incorporated into the recommended list of accountability measures. The creation and updates of this list will serve as guidance and a starting point for health-system pharmacies to engage in systemwide improvement of clinical care. References 1. Manasse HR, Andrawis MA. Accepting accountability for the medication-use system. Am J Health-Syst Pharm. 2011; 68:1444-8.

1672

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

SPECIAL FEATURE  Pharmacy accountability

2. National Quality Forum. Safe practices for better healthcare: 2010 update: a consensus report. www.qualityforum.org/ Publications/2010/04/Safe_Practices_for _Better_Healthcare_%E2%80%93_ 2010_Update.aspx (accessed 2013 Mar 13). 3. Chisholm-Burns MA, Kim Lee J, Spivey CA et al. US pharmacists’ effect as team members on patient care. Med Care. 2010; 48:923-33. 4. American Society of Health-System Pharmacists. Proceedings of the 62nd annual session of the ASHP House of Delegates. June 6 and 8, 2010. www.ashp.org/ DocLibrary/Policy/HOD/Proceedings 62ndAnnualSession.aspx (accessed 2014 Aug 4). 5. American Society of Health-System Pharmacists. Proceedings of the 63rd annual session of the ASHP House of Delegates. www.ashp.org/DocLibrary/Policy/ HOD/Proceedings63rdAnnualSession. aspx (accessed 2014 Jun 24). 6. Zellmer WA, Cobaugh DJ, Chen D. Three signals from the Pharmacy Practice Model Summit. Am J Health-Syst Pharm. 2011; 68:1077. 7. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency hospitalizations for adverse drug events in older Americans. N Engl J Med. 2011; 365:2002-12. 8. Office of Disease Prevention and Health Promotion. Solicitation of written comments on draft National Action Plan for Adverse Drug Event Prevention.

9.

10.

11.

12. 13.

14.

15.

www.gpo.gov/fdsys/pkg/FR-2013-09-04/ pdf/2013-21434.pdf (accessed 2014 Jun 25). Mahan CE, Spyropoulos AC. ASHP therapeutic position statement on the role of pharmacotherapy in preventing venous thromboembolism in hospitalized patients. Am J Health-Syst Pharm. 2012; 69:2174-90. Rosendaal FR, Cannegieter SC, van der Meer FJ, Briët E. A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Haemost. 1993; 69:236-9. Schulman S, Parpia S, Stewart C et al. Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable International Normalized Ratios: a randomized trial. Ann Intern Med. 2011; 155:653-9,W201-3. Guyatt G. Antithrombotic therapy and prevention of thrombosis: executive summary. Chest. 2012; 142:7s-47s. Varghese P, Gleason V, Sorokin R et al. Hypoglycemia in hospitalized patients treated with antihyperglycemic agents. J Hosp Med. 2007; 2:234-40. Inzucchi SE, Bergenstal RM, Buse JB et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012; 35:1364-79. American Society of Health-System Pharmacists. ASHP statement on the

16.

17.

18.

19.

20.

21.

22.

pharmacist’s role in hospice and palliative care. Am J Health-Syst Pharm. 2002; 59:1770-3. American Society of Health-System Pharmacists. ASHP guidelines on emergency medicine pharmacist services. Am J Health-Syst Pharm. 2011; 68:e81-95. Myers RP, Li B, Fong A et al. Hospitalizations for acetaminophen overdose: a Canadian population-based study from 1995 to 2004. BMC Public Health. 2007; 7:143. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in antimicrobial stewardship and infection prevention and control. Am J Health-Syst Pharm. 2010; 67:575-7. Bratzler DW, Dellinger EP, Olsen KM et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283. Mandell LA, Marrie TJ, Grossman RF et al. Summary of Canadian guidelines for the initial management of communityacquired pneumonia: an evidence-based update by the Canadian Infectious Disease Society and the Canadian Thoracic Society. Can J Infect Dis. 2000; 11:237-48. Evans AT, Husain S, Durairaj L et al. Azithromycin for acute bronchitis: a randomised, double-blind, controlled trial. Lancet. 2002; 359:1648-54. Ross A. Diagnosis and treatment of acute bronchitis. Am Fam Physician. 2010; 82:1345-50.

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

1673

1674 Numerator

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

VTE-6 Hospital Acquired Potentially Preventable Venous Thromboembolism

VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy VTE-5 Venous Thromboembolism Warfarin Therapy Discharge Instructions

VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis

Patients with documentation that they or their caregivers were given written discharge instructions or other educational material about warfarin that addressed all of the following: 1. Compliance issues 2. Dietary advice 3. Follow-up monitoring 4. Potential for adverse drug reactions and interactions Patients who receive no VTE prophylaxis before the VTE diagnostic test order date

Patients who receive VTE prophylaxis or have documentation why no VTE prophylaxis was given: 1. The day of or the day after ICU admission (or transfer) 2. The day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients who received overlap therapy

Anticoagulant safety Inpatient venous thromboembolism (VTE) measures VTE-1 Venous Patients who receive VTE prophylaxis Thromboembolism or have documentation why no Prophylaxis VTE prophylaxis was given

Measure Title/Description

Joint Commission/ no longer endorsed (previously NQF# 375)

Joint Commission/ no longer endorsed (previously NQF# 376)

CMS core measure: aligns with the NQS

CMS core measure: aligns with the NQS

Patients with confirmed VTE who received warfarin

Patients with confirmed VTE discharged on warfarin therapy

Patients who developed confirmed VTE during hospitalization

Continued on next page

Joint Commission/NQF endorsed: NQF# 373

CMS core measure: aligns with the NQS

Patients directly admitted or transferred to the ICU

Measure Developer/ Endorsement Status

Joint Commission/ National Quality Forum (NQF) endorsed: NQF# 371 Joint Commission/NQF endorsed: NQF# 372

Implementation Guidance

Centers for Medicare and Medicaid Services (CMS) core measure: aligns with the National Quality Strategy (NQS) CMS core measure: aligns with the NQS

All patients

Denominator

Appendix A­—Accountability measures recommended by the ASHP Pharmacy Accountability Measures (PAM) Work Group

SPECIAL FEATURE  Pharmacy accountability

INR for individuals taking warfarin and interacting antiinfective medications

Outpatient anticoagulant measures Percent time in therapeutic International Normalized Ratio (INR) range (TTR): mean TTR achieved among patients who received prescriptions for warfarin and had sufficient INR values to calculate TTR Lack of INR monitoring for individuals on warfarin

Measure Title/Description

Appendix A­ (continued)

Number of episodes with a newly started interacting antiinfective medication with an overlapping days’ supply of warfarin

Based on NQF 0555: This measure originally tracks monthly intervals and does not correspond to current recommendations; therefore, the denominator has been modified to be consistent with current clinical practice Based on NQF 0556: For antiinfectives with classification 1–3 (inclusive of the following: fluconazole, voriconazole, griseofulvin, itraconazole, ketoconazole, terbinafine, rifampin, nevirapine, cefotetan, ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin, ofloxacin, azithromycin, clarithromycin, erythromycin, nafcillin, dicloxacillin, demeclocycline, doxycycline, minocycline, tetracycline, oxytetracycline, rifabutin, rifapentine, sulfamethoxazole, chloramphenicol, telithromycin, metronidazole, tinidazole, peginterferon alfa-2b, atovaquone, mefloquine, and proguanil), follow-up is required within 3–7 days. Other antiinfectives listed as classification 4 within the CMS specifications require follow-up every 14 days.

Individuals with warfarin claims for at least 42 days or in range in the last 56 days in stable patients

Sum of the percentage of monthly intervals without an INR test for each individual in the denominator

Number of episodes in the denominator with an INR test performed 3–7 days after the start date of an antiinfective

The Rosendaal et al. method is the preferred calculation for TTRa,b

Implementation Guidance

Patients, 18 years and older, who received prescriptions for warfarin and had sufficient INR values to calculate TTR

Denominator

Mean TTR achieved among patients who received prescriptions for warfarin and had sufficient INR values to calculate TTR

Numerator

Continued on next page

Modified by PAM Work Group

Modified by PAM Work Group

Department of Veterans Affairs/not endorsed

Measure Developer/ Endorsement Status

SPECIAL FEATURE  Pharmacy accountability

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

1675

1676

Number of patients with INR value of >5

Numerator

Glycemic control Inpatient glycemic control measures Severe hypoglycemia Total number of hypoglycemic events (200 mg/ dL) at least 6 hours apart, a single elevated blood glucose measurement if only 1 value is available that day, or no blood glucose level was measured that day and the preceding 2 days were not normoglycemic days) for each admission in the denominator Outpatient glycemic control measures An HbA1c test performed during the Comprehensive diabetes care: percentage of members 18– measurement year, as identified 75 years of age with diabetes by claim/encounter or automated (type 1 and type 2) who had laboratory data. Use any code listed glycosylated hemoglobin in Table CDC-D in the original (HbA1c) testing measure documentation to identify HbA1c tests

Supratherapeutic INR

Measure Title/Description

Appendix A (continued)

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014 CMS/NQF endorsed: NQF# 2362

NCQA/NQF endorsed: NQF# 057

Threshold may be adjusted if needed

National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS); more frequent testing may be required

Total number of admissions with diagnosis of diabetes mellitus, at least one administration of insulin or any antidiabetic medication except metformin, or at least one elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay

Members age 18–75 years as of December 31 of the measurement year with diabetes (type 1 and type 2)

Continued on next page

CMS/NQF endorsed: NQF# 2363

CMS/not endorsed

Measure Developer/ Endorsement Status

Threshold may be adjusted if needed

Australian Council on Healthcare Standards: aligns with the NQS and PfP

Implementation Guidance

Total number of hospital days with at least one antidiabetic agent administered

Total number of patients on warfarin therapy

Denominator

SPECIAL FEATURE  Pharmacy accountability

Outpatient antibiotic stewardship measures Avoidance of antibiotic treatment From the denominator, those who in adults with acute bronchitis were dispensed a prescription for antibiotic medication on or three days after the index episode start date

Patients age 18–64 years with a negative medication history, negative comorbid condition history, and negative competing diagnosis, who had an outpatient emergency department visit with any diagnosis of acute bronchitis during the intake period

NCQA HEDIS

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

Continued on next page

NCQA/NQF endorsed: NQF# 058

CMS/NQF endorsed: NQF# 147

CMS/NQF endorsed: NQF# 529

CMS core measure: as a minimum standard with the understanding that recommendations are currently changing and may promote discontinuation of agent immediately after surgery CMS core measure: Streptococcus pneumoniae is the most common pathogen. The prevalence to resistance is increasing. Appropriate coverage as outlined in measure increases survival. This measure is for both ICU and non-ICU patients

All selected surgical patients with no evidence of prior infection

Pneumonia patients 18 years and older

CMS/NQF endorsed: NQF# 528

NCQA/NQF endorsed: NQF# 059

Measure Developer/ Endorsement Status

CMS core measure

NCQA HEDIS

Implementation Guidance

All selected surgical patients with no evidence of prior infection

Members age 18–75 years as of December 31 of the measurement year with diabetes (type 1 and type 2)

Use automated laboratory data to identify the most recent HbA1c test during the measurement year. The member is numerator compliant if the most recent automated HbA1c level is >9.0% or is missing a result, or if an HbA1c test was not done during the measurement year

Comprehensive diabetes care: percentage of members 18–75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is >9.0% (poorly controlled)

Antimicrobial stewardship Inpatient antibiotic stewardship measures SCIP-Inf-2a Prophylactic Number of surgical patients who Antibiotic Selection for received prophylactic antibiotics Surgical Patients recommended for their specific surgical procedure SCIP-Inf-3a Prophylactic Number of surgical patients Antibiotics Discontinued with prophylactic antibiotics Within 24 hours After Surgery discontinued within 24 hours End Time after anesthesia end time (48 hours for coronary artery bypass graft or other cardiac surgery) PN-6 Initial Antibiotic Pneumonia patients who receive Selection for Communityan initial antibiotic regimen Acquired Pneumonia in consistent with current guidelines Immunocompetent Patients during the first 24 hours of their hospitalization

Denominator

Numerator

Measure Title/Description

Appendix A­ (continued)

SPECIAL FEATURE  Pharmacy accountability

1677

1678 Numerator

Number of patients with documentation of a second-level review by a pharmacist or pain specialist

Am J Health-Syst Pharm—Vol 71 Oct 1, 2014

Number of long-acting opioids (e.g., fentanyl patch, oxycodone extended release, methadone) prescribed “as needed”

Total number of long-acting opioids prescribed

Individuals receiving prescription drug claims for acetaminophen-containing products

Patients prescribed a high-risk opioid (methadone, fentanyl i.v. and patches, hydromorphone i.v., meperidine)

Patients prescribed opioids

Denominator

Pharmacy Quality Alliance (PQA) draft measure specification (embargoed); this measure can be used in both the inpatient and outpatient settings and is based on a PQA draft measure FDA blueprint for prescriber education for extended-release and longacting opioidse

Minnesota Hospital Association Road Map to a Medication Safety Programc Joint Commission Sentinel Event Alertd: prefer the conversion of all agents to morphine equivalents and use in both inpatient and outpatient settings

Implementation Guidance

PAM Work Group/not endorsed

PQA/awaiting endorsement process progression

Minnesota Hospital Association/not endorsed PAM Work Group /not endorsed

Measure Developer/ Endorsement Status

b

a

Schulman S, Parpia S, Stewart C et al. Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable International Normalized Ratios: a randomized trial. Ann Intern Med. 2011; 155:653-9, W201-3. Rosendaal FR, Cannegieter SC, van der Meer FJ, Briët E. A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Haemost. 1993; 69:236-9. c Minnesota Hospital Association: Road Map to a Medication Safety Program. www.mnhospitals.org/portals/0/documents/ptsafety/ade/medication-safety-roadmap.pdf (accessed 2014 Aug 6). d Joint Commission. Sentinel Event Alert, Issue 49. www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12final.pdf (accessed 2014 Aug 6). e Food and Drug Administration. www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM277916.pdf (accessed 2013 Apr 23).

Long-acting opioids prescribed “as needed”

Outpatient pain management measures Patients in the denominator who Chronic use of high-dose receive more than a daily acetaminophen acetaminophen dose of 4 g for ≥10 days

Second-level review by pharmacist or pain specialist for patient’s prescribed highrisk opioids

Pain management Inpatient pain management measures Number of naloxone administrations Naloxone reversal used for reversal of oversedation

Measure Title/Description

Appendix A (continued) SPECIAL FEATURE  Pharmacy accountability

Appendix B—Toolkit resources

ASHP Research and Education Foundation. ASHP Foundation antithrombotic use assessment tool for hospitals and health systems. www.ashpfoundation.org/Main MenuCategories/PracticeTools/OptimizingAntithrombotic-Management-AnAssessment-Tool-for-Hospitals-and-HealthSystems American Society of Health-System Pharmacists. ASHP medication management in care transitions. http://media.pharmacist. com/practice/ASHP_APhA_Medication ManagementinCareTransitionsBestPractices Report2_2013.pdf ASHP Research and Education Foundation. Enhancing insulin use safety in hospitals: practical recommendations from the ASHP Foundation expert consensus panel. www.ashpfoundation.org/MainMenu Categories/PracticeTools/Insulin-UseSafety-Recommendations Food and Drug Administration. FDA blueprint for prescriber education for extended release and long acting opioid analgesics. www.fda. gov/drugs/drugsafety/informationbydrug class/ucm163647.htm Institute for Healthcare Improvement. Institute for Healthcare Improvement global trigger tool for measuring adverse events. www.ihi. org/resources/Pages/IHIWhitePapers/IHI GlobalTriggerToolWhitePaper.aspx Institute for Healthcare Improvement. Institute for Healthcare Improvement trigger tool for measuring adverse drug events. www.ihi. org/resources/Pages/Tools/TriggerToolfor MeasuringAdverseDrugEvents.aspx Agency for Healthcare Research and Quality. MATCH toolkit for medication reconciliation. www.ahrq.gov/professionals/qualitypatient-safety/patient-safety-resources/ resources/match/index.html National Quality Forum. National voluntary consensus standards for medication management. www.qualityforum.org/ Publications/2010/05/National_Voluntary_ Consensus_Standards_for_Medication_ Management.aspx Health Resources and Services Administration. Patient Safety and Clinical Pharmacy Services Collaborative: Change Package 6.0. www.amda.com/advocacy/Attachment_j12a.pdf Institute of Medicine. Preventing medication errors: quality chasm series. www.iom. edu/Reports/2006/Preventing-MedicationErrors-Quality-Chasm-Series.aspx Minnesota Hospital Association. Road map to a medication safety program. www.mn hospitals.org/ade

Copyright of American Journal of Health-System Pharmacy is the property of American Society of Health System Pharmacists and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

A suite of inpatient and outpatient clinical measures for pharmacy accountability: recommendations from the Pharmacy Accountability Measures Work Group.

A suite of inpatient and outpatient clinical measures for pharmacy accountability: recommendations from the Pharmacy Accountability Measures Work Group. - PDF Download Free
669KB Sizes 4 Downloads 7 Views