Depression in Primary Care: Drowning in the Mainstream or Left on the

On September 16, 2009, Harold Alan Pincus made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (1.4 MB) (Plugin Software Help).

Slide 1

Medication Management Measures: NQF and Beyond

Harold Alan Pincus, MD
Professor and Vice Chair, Department of Psychiatry
Associate Director, Irving Institute for Clinical and Translational Research
Columbia University
Director of Quality and Outcomes Research
NewYork-Presbyterian Hospital
Senior Scientist, RAND Corporation

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

Slide 2

Medication Management Measures: NQF and Beyond

• Background/Context
• NQF Process
• Steering Committee Consensus
  • Conclusions
  • Concerns
• Issues/Questions in Measuring Medication Management Quality

Slide 3

Linking Policy, Practice and Research

Image: A triangle is shown with Research, Policy, and Practice on each point.

Slide 4

Policy Context

• [image of an arrow pointing up] 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?

Slide 5

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

Note: On the left of the slide is an image of a book cover. The book is titled "To Err is Human, Building a Safer Health System."

Slide 6

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!

Note: On the left of the slide is an image of a book cover. The book is titled "Crossing the Quality Chasm, A new Health System for the 21st Century."

Slide 7

Improving the Quality of Health Care for Mental and Substance-Use Conditions

Note: An image of a book cover is shown. The book is titled "Improving the Quality of Health Care for Mental and Substance-Use Conditions."

Slide 8

"Crossing the Quality Chasm"

Image: Silhoettes of three backpackers crossing a bridge with mountains behind them is shown.

Slide 9

Preparing for the Future

The four main points are:

Consumer Participation
Clinical Perspectives
Integrative Processes
Leadership Support
 

All four of the above point to the following structure:

• 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

Slide 10

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

Slide 11

"6 P" Conceptual Framework

Patient/Consumer

• Enhance self-management/participation
• Link with community resources
• Evaluate preferences and change behaviors

Providers

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

Practice/Delivery Systems

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

Plans

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

Purchasers (Public/Private)

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

Populations and Policies

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

Slide 12

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

Slide 13

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

Slide 14

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/Improvement
  • Importance—PH and improvement
  • Scientific acceptability—reliable/valid
  • Useability—decision making/6P's
  • Feasibility—data available/burden
• Steering Committee—open consensus/interactive
• Member and public comment

Slide 15

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

Slide 16

Recommended Measures

Adherence 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

Slide 17

Recommended Measures (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)

Slide 18

Steering Committee Concerns

• Submitted (and recommended) measures do not represent full array needed to assess/improve quality
• Measures not linked or harmonized across multiple developers
• Single prescription for chronic diseases
• Multiple, conflicting, confusing ways to measure similar concepts (i.e. adherence)
• Limited testing of measures
• Need for continual updating
• Significant R and D needed for measures addressed/linked to outcomes, are patient-centered and cover a broader array of conditions, settings, populations

Slide 19

Proposed Standard Specifications for Adherence Measurement

Numerator

1. New Users: For patients with no prescription in the 180 days prior to the measurement period, sum of:
   Days' supply of all medications from the first prescription until the end of the measurement period.
   **Remove the days' supply that extend past the end of the measurement period.
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.

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

**Multiply by 100—cannot exceed 100%

Slide 20

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

Slide 21

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

Slide 22

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

Slide 23

Antidepressant Medication Management: Optimal Practitioner Contacts Trends, 1998-2005

Image: A line graph of Optimal Practitioner Contacts Trends is shown. The Commercial line (red) is around 20% from 1998 to 2004. The Medicaid line (purple) is around 20% from 2001 to 2005. The Medicare line (green) is around 10% from 2001 to 2005.

Slide 24

Antidepressant Medication Management: Effective Continuation Phase Treatment Trends, 1998-2005

Image: A graph of Effective Continuation Phase Treatment Trends is shown. The Commercial line (red) is around 40% and rises slightly from 1998 to 2005. The Medicaid line (purple) is around 40% and rises slightly from 2001 to 2005. The Medicare line (green) is around 30% from 2001 to 2005.

Slide 25

"Crossing the Quality Chasm"

Image: Silhoettes of three backpackers crossing a bridge with mountains behind them is shown.

Slide 26

Image: A bridge is shown.