PQA’s Patient Safety Performance Measure Concepts Currently Under Development

This material was prepared by Telligen, Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-C3-10/2015-11295

Katy Brown PharmDkaty.brown@area-D.hcqis.org Work (515) 453-8124Cell (712) 299-6850http://www.telligenqinqio.com/resources/medication-safety

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PQA’s Patient Safety Performance Measure Concepts Currently Under

Development

Telligen LAN WebinarDecember 16th, 2015

PQA

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Speakers

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Lynn Pezzullo, RPh, CPEHR, is Senior Director, Performance Measurement at PQA. In this role she ensures the successful

Lisa E. Hines, PharmD, is Director of Performance Measurement at PQA. In this role she facilitates the development of new performance

development, testing and maintenance of PQA measures and quality improvement indicators. Previous experience includes QIO, community pharmacy, training and development and change management.

measures and quality improvement indicators. Previous experience includes academia – with research and educational projects aimed to improve patient safety, family medicine and managed care.

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Learning Objectives

1. Describe patient safety measure concepts that align with the National ADE Action Plan priorities.

2. Discuss how these draft measure concepts could be used by QIOs to support their quality improvement efforts with providers.

3. Articulate the challenges with documenting medication reconciliation in the long-term care setting.

4. Distinguish between a performance measure and quality improvement indicator.

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What is thePharmacy Quality Alliance?

Established in 2006 as a public-private partnership through leadership of CMS

Now operates as an independent, nonprofit 501(c)3 corporation

Consensus-based, multi-stakeholder, transparent alliance with 178 members* and over 400 active representatives from these member organizations

PQA5 *As of 10/29/15

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PQA’s Mission Statement

Improve the quality of medication management and use across health care settings with the goal of improving patients’ health through a collaborative process to develop and implement performance measures and recognize examples of exceptional pharmacy quality.

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Develop quality medication performance measures for pharmacy services and drug plans

Demonstration projects for pharmacy quality measures and improving outcomes

Provide education for member organizations on quality measures and performance improvement and the changing performance-based landscape

Connect healthcare professionals to quality initiatives

Advocate for appropriate and safe medication use in the national quality dialogue

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Key Activities of PQA

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Medication Adherence and Persistence Proportion of Days Covered (PDC): Beta-Blockers, Renin

Angiotensin System Antagonists*, Calcium-Channel Blockers, Diabetes Medications*, Statins*, Antiretroviral Medications, Non-Warfarin Oral Anticoagulants

Primary Medication Non-Adherence

Appropriate Medication Use Diabetes Medication Dosing* Absence of Controller Therapy, Suboptimal Asthma Control Cholesterol Management in Coronary Artery Disease Statin Use in Persons with Diabetes

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Medication Measure Domains

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*PQA measures used in Medicare Star Ratings, Display Measures or Health Insurance Marketplace Quality Ratings System

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Medication Safety Use of High-Risk Medications in the Elderly* Opioid overuse measure set Use of Benzodiazepine Sedative Hypnotics in the Elderly Drug-Drug Interactions* Antipsychotic Use in Children Under 5 Years Antipsychotic Use in Persons with Dementia (using claims data) Antipsychotic Use in Persons with Dementia (using MDS data)

Medication Therapy Management Completion Rate for Comprehensive Medication Reviews*

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Medication Measure Domains (cont’d)

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*PQA measures used in Medicare Star Ratings, Display Measures or Health Insurance Marketplace Quality Ratings System

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Medicare Part D Plan Ratings Star measures Display measures

Health Insurance Marketplace Quality Rating System

Accreditation programs URAC & CPPA

National Business Coalition on Health

eValue8 (health plan screening and evaluation)

Pharmacies and Health Plans EQuIPP

Physician Offices IHA of California Community Care of North

Carolina

Pay-for-Performance Pharmacy Networks

Inland Empire Pharmacy First CVS Health/Silverscript

Medicaid Care Coordination Programs

Community Care of North Carolina

Medicare-Medicaid Dual-Eligible Pilots

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Where PQA Measuresare Being Used Today

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PQA’s MeasureDevelopment Process

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Measure Concept Idea

Measure Concept

Development /Specification

Draft Measure Testing

Measure Endorsement

Measure Update

Measure Update Panel

Measure Advise-ment Group

Measure Development Teams/Task Forces

PQA General Membership

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Implementation Advisory Panel

Patient Advisory Panel

Risk Adjustment Advisory Panel

Stakeholder Advisory Panels

Quality Metrics Experts Panel

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MeasureEvaluation Criteria

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• Important to measure and report• Evidence that measurement and

reporting will have a positive impact Importance

• Consistent (reliable) and credible (valid) results about quality of care

Scientific Acceptability

• Data readily available, retrievable without undue burden

• Can be implemented for performance measurement

Feasibility

• Meaningful, understandable, and useful for stakeholdersUsability

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Provide a benchmark, allowing for comparison across organizations or systems;

Are often mandated by government programs or payers;

Include pre-established criteria with no ability for any organization to modify the criteria; and

Can be used for contract fulfillment, public reporting, and pay-for-performance programs.

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Performance Measures

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Do not provide a benchmark; rather they are used within an organization to establish a baseline;

Allow organizations to implement quality improvement strategies to shift from baseline;

Are used to better understand efficiency and outcomes of internal processes;

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Quality Improvement Indicators

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Are inherently more flexible—can be applied to different populations over different time periods;

NOT used for external comparisons, public reporting, or pay-for-performance programs; and

May become performance measures when able to fully specify and/or standardize the full metric.

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Quality Improvement Indicators (cont’d)

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1. Hospital Admission or ED Visit for Bleeding Events Associated with Anticoagulant Medications

2. Serious Hypoglycemic Events Requiring Hospital Admission or ED Visit Associated with Anti-Diabetic Medications

3. Hospital Admission or ED Visit for Opioid Overdose

4. Triple Threat: Concurrent Use of Opioids, Benzodiazepine or Nonbenzodiazepine Sedative/Hypnotics, and Muscle Relaxants

5. Medication Reconciliation Upon Admission to Long Term Care (QII)

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PQA’s Medication Safety Measures Under Development

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Alignment with the National ADE Action Plan

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AD

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ctio

n P

lan

AnticoagulantsHospital & ED Utilization Related to

Anticoagulants/Bleeding Event (Measure Concept)

Diabetes AgentsSerious Hypoglycemic Events

Requiring Hospital Admission or ED Visit Associated with Anti-Diabetic

Medications (Draft Measure)

Opioids

Hospital & ED Utilization Related to Prescription Opioids (Measure Concept)

Triple Threat (Measure Concept)

Opioid Overuse Measure Set (PQA Endorsed)

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Hospital Admission or ED Visit for Bleeding Events Associated with Anticoagulants

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Status: Measure concept, in development Measure Type: Outcome Description

• Rate of bleeding events among individuals receiving anticoagulant medications that result in a hospitalization and/or ED visit (+/- urgent care visit)

• Expressed as number of events per 10,000 member months

• Lower value is indicative of higher quality Intended Use: Health plans – performance measurement Data Source: Prescription claims and medical claims

(diagnosis code)

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Hospital Admission or ED Visit for Bleeding Events Associated with Anticoagulants

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Eligible Population• Individuals with one or more prescription claims for an

anticoagulant medication Denominator

• The number or member months occurring within the days supply of a target medication

Numerator• The number of unique events where individuals in the

denominator have evidence of a hospital admission or ED visit (+/- urgent care visit) with a bleeding event diagnosis occurring within the days supply of a target medication.

Exclusions: None

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Hospital Admission or ED Visit forSerious Hypoglycemic Events

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Status: Draft measure, in testing Measure Type: Outcome Description

• Rate of serious hypoglycemic events among individuals receiving anti-diabetic medications that result in a hospitalization and/or ED visit (+/- urgent care visit)

• Expressed as number of events per 10,000 member months

• Lower value is indicative of higher quality Intended Use: Health plans – performance measurement Data Source: Prescription claims and medical claims

(diagnosis code)

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Hospital Admission or ED Visit forSerious Hypoglycemic Events

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Eligible Population• Individuals with one or more prescription claims for a diabetic

medication Denominator

• The number or member months occurring within the days supply of a target medication

Numerator• The number of unique events where individuals in the

denominator have evidence of a hospital admission or ED visit (+/- urgent care visit) with a serious hypoglycemic event diagnosis occurring within the days supply of a target medication

Exclusions: None

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Status: Measure concept, in development Measure Type: Outcome Description

• Rate of events among individuals receiving prescription opioid medications that have evidence of an opioid-related hospitalization and/or ED visit (+/- urgent care visit)

• Expressed as number of events per 10,000 member months

• Lower value is indicative of higher quality Intended Use: Health plans – performance measurement Data Source: Medical and prescription claims

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Hospital Admission or ED Visit forOpioid Overdose

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Eligible Population• Individuals with one or more prescription claims for an opioid

Denominator• The number or member months occurring within the days

supply of a target medication Numerator

• The number of unique events where individuals in the denominator have evidence of a hospital admission or ED visit (+/- urgent care visit) with an opioid-related diagnosis occurring within the days supply of a target medication

Numerator Exclusions• Intentional (self harm) poisoning by opioids

• Heroin-related diagnoses PQA

Hospital Admission or ED Visit forOpioid Overdose

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Status: PQA-endorsed performance measures Measure Type: Process Description: Use of Opioids from Multiple Providers or

at High Dosage in Persons Without Cancer (expressed as a proportion; XX out of 1,000)

1. Measure 1: Use of Opioids at High Dosage

2. Measure 2: Use of Opioids from Multiple Providers

3. Measure 3: Use of Opioids at High Dosage and from Multiple Providers

Intended Use: Health plans – performance measurement Data Source: Prescription claims and Rx Hierarchical

Condition Codes (RxHCC)

Multi-Provider, High-DoseOpioid Use

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Multi-Provider, High-DoseOpioid Use (cont’d)

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Eligible Population• ≥18 years

Denominator• Two or more prescription claims for opioids filled on at least two

separate days, for which the sum of the days supply is > 15. Numerator

1. Prescriptions for opioids with a daily dosage >120mg MED for> 90 consecutive days.

2. Prescriptions for opioids from ≥4 prescribers AND ≥4 pharmacies.

3. Prescriptions for opioids with a daily dosage >120mg MED for ≥90 consecutive days, AND who received opioid Rx from ≥4 prescribers AND ≥4 pharmacies.

Exclusions: Cancer, hospice

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Triple Threat

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Status: Measure concept, in development Measure Type: Process Description

• Percentage of inidividuals with concurrent use of opioids, benzodiazepine or nonbenzodiazepine sedative/hypnotics, and muscle relaxants

Intended Use: Health plans – performance measurement Data Source: Prescription claims

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Eligible Population• ≥18 years

Denominator• ≥2 Rx for opioids filled on ≥2 separate days, for which days

supply is ≥15 Numerator

• ≥1 opioid Rx for which the days supply is ≥7; AND

• ≥1 benzodiazepine or nonbenzodiazepine sedative/hypnotic Rx for which the days supply is ≥7; AND

• ≥1 muscle relaxant Rx for which the days supply is ≥7; AND

• ≥7 cumulative overlapping days supply for all 3 classes of medications

Exclusions: None

Triple Threat (cont’d)

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Medication Reconciliation UponAdmission to Long Term Care

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Status: QII concept, in development Metric Type: Process Description

• Percentage of admissions to a skilled nursing facility or intermediate care faciliy for which medication reconcilaition is completed within 3 days from the date of admission.

Intended Use: SNF/ICF – quality improvement Data Source: Medical claims or medical records

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Medication Reconciliation UponAdmission to Long Term Care

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Eligible Population• ≥18 years

Denominator• Admissions

Numerator• Med rec conducted on or within 3 days from the date of admission

• Pharmacist, prescriber, or other qualified healthcare provider, with access to information needed to ensure the most accurate list of all medications that the patient is taking, must conduct this reconciliation

• Not required, but a pharmacist should conduct the med rec, & the patient (or representative) should be included in the process when possible

Exclusions: None

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Not included in Long-Term Care Minimum Data Set (MDS) 2.0• Expected in MDS 3.0

CPT (Current Procedure Terminology) codes inconsistently used• MTM CPT 99605-99607- Modifier 32

• SNF E/M CPT 99307-99310

• CPT 99495 & 99496 transitional care management services

• CPT 1160FA SNOMED CT (Systemized Nomenclature of Medicine—

Clinical Terms) codes not widely used• Medication reconciliation - 430193006 (Parent Concept ID)

• Medication reconciliation by pharmacist (procedure) – 428701000124107

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Challenges with Documenting Medication Reconciliation in LTC

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Complete specifications for measure concepts

Develop clinical risk adjustment models for draft outcome measures

Execute testing plans with testing partners

PQA membership endorsement consideration

Encourage adoption and implementation of endorsed measures

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PQA Next Steps

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Measure Alignment

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Layered Diabetes Care

Comprehensive Diabetes Care

Hypoglycemic Events

Syste

m

Leve

lExternal

Accountability Measure Set

Internal Management

Measures

Po

pulation

L

evel

Pro

vider

Leve

l

Internal Improvement

Measures

Composite Measure

Blood Pressure

Test

HbA1c Test

Tobacco Assess-

ment

Lipid Panel

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1. What metrics are QIOs currently using to evaluate the impact of their interventions:

• Related to reducing incidence of ADEs?

• Related to reducing admission/re-admission rates?

2. Once the PQA measure development and endorsement process is complete, how can the PQA measures be helpful in showing QIO impact on ADEs related to hypoglycemic, anticoagulant, and opioid use?

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Discussion Questions

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Contact information:

Lynn Pezzullo, RPh, CPEHR Senior Director, Performance Measurementlpezzullo@PQAalliance.org

Lisa Hines, PharmDDirector, Performance Measurementlhines@pqaalliance.org

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Questions

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