What Happens When Healthcare Measurements Don’t Keep Up with Guidelines?

The Appropriate Treatment of Hypertension in Diabetes Medicare Part D Star Rating
December 2014, Vol 2, No 6 - Inside Pharmacy
Emily Hanson, PharmD
Tripp Logan, PharmD

When working in healthcare, quality is always being measured. There are many acronyms, measures, and surveys that are used in everyday conversations in pharmacy. You may hear “HCAHPS,” “Star Rating,” “PDC,” adherence rates, readmission rates—the list goes on and on—and you find yourself asking: “What do these measurements mean? What are they based on?”

We would like to think that the measurements are based on evidence, whether that evidence comes from expert opinion, best practice, or current guidelines. Often the measurements are also based on guidelines or other evidence-based medicine. But what happens when guidelines change? How do these measurements keep up?

The CMS 5-Star Rating
A good example of an existing quality measure that is not supported by new clinical guidelines is the Appropriate Treatment of Hypertension in Diabetes. This quality measure, as well as 4 other pharmacy-driven quality measures, is included in the Centers for Medicare & Medicaid Services (CMS) Star Rating formula, and account for a large percentage of a Medicare Part D Plan’s overall rating.

CMS uses this 1-5 Star Rating system to assess the quality of Medicare Part D Plans. The more stars a Medicare Part D Plan has, the better perceived quality, and the more incentives it can receive. There are 5 heavily weighted measures in the CMS Star Rating formula that pharmacies can directly influence. Three of these pharmacy measures assess medication adherence in diabetes, hypertension, and cholesterol medication.

Another pharmacy measure evaluates the percentage of a Medicare plan’s population that is 65 years of age or older and taking medications with a high risk for adverse events. The fifth measure, and the focus of this article, looks at Medicare Part D Plan participants with diabetes and hypertension, and measures the percentage of patients taking recommended hypertension medication.

Measuring Diabetes and Hypertension
When the Star Rating quality measure for hypertension treatment in diabetes was created, it was based on current clinical guidelines. At the time, recommendations from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) served as the basis for the quality measure.

According to the JNC 7 Express guidelines, patients with diabetes and hypertension often need two or more drugs to achieve goal blood pressure. Thiazide-type diuretics should be used as initial therapy for most patients, either alone or in combination with another class of medications. Angiotension-converting enzyme inhibitor (ACEI) or angiotension receptor blocker (ARB)-based treatments favorable affect the progression of diabetic nephropathy and reduce albuminuria and ARBs have been shown to reduce the progression to macroalbuminuria.1 With JNC 7 recommending ACEI or ARB-based treatments because of their positive effects on the kidneys the current American Diabetes Association (ADA) guidelines also use JNC 7 to make their recommendations for patients with hypertension and diabetes. They recommend that patients with diabetes and hypertension receive an ACEI or an ARB as initial treatment, if tolerated by the patient.2

The Appropriate Treatment of Hypertension in Diabetes Star Rating measure evaluates whether patients with diabetes and hypertension fill their prescription for the recommended hypertension medication in the renin-angiotensin system antagonist class. Based on the JNC 7 guidelines, the Appropriate Treatment of Hypertension in Diabetes performance measure, used by CMS and others, is sound, evidence-based, and rooted in nationally accepted clinical recommendations.

JNC 8 Guidelines
In February 2014, the JNC on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure released their eighth report (JNC 8), and, in many ways, it changed the way hypertension is treated.

There were a number of controversial changes between JNC 7 and JNC 8, and the recommendations for the treatment of patients with hypertension in diabetes were among them. One of the changes that sparked controversy applies here. Recommendation 6 of the report states that in the general nonblack population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic, calcium channel blocker (CCB), ACEI, or ARB.3 Recommendation 7 of the report states that in the general black population, including those with diabetes, initial antihypertensive treatment should include a thiazide-type diuretic or CCB.

With these new recommendations, thiazide-type diuretics and CCBs are appropriate treatment options along with ACEIs or ARBs for the treatment of patients with hypertension and diabetes. The ADA guidelines have not been updated since JNC 8 was released, and, as of today, the guidelines still are limited to an ACEI or an ARB as initial treatment for hypertension in diabetes. However, according to these new JNC 8 guidelines for hypertension treatment in diabetes, the current CMS Star Rating performance measure is outdated.

Local, National Implications of Data
Currently, health plans are being evaluated based on whether patients with diabetes are taking an ACEI or an ARB. What happens if they are on a CCB or thiazide-type diuretic? According to current guidelines, these would also be appropriate choices for managing hypertension in patients with diabetes.

At one of our pharmacies, we decided to look at these numbers and assess how many patients with diabetes received treatment for hypertension that reflected current clinical guidelines, but are not reflected in the current Star Rating performance measurement. Of 284 patients who have diabetes and hypertension, 249 were on an ACE/ARB/direct renin inhibitor (DRI) (87.7%). Moreover, in 35 patients (12.3%) who were not on an ACE/ARB/DRI, 26 were taking CCB or thiazide (9.1%). These data indicate that 35 patients represent a “gap in care” based on the current Star Rating performance measurement, and only 9 patients (3.2%) were actually not on current appropriate therapy based on JNC 8 guidelines.

At our pharmacy, according to the most current clinical guidelines, only 3.2% of patients with diabetes and hypertension are not being treated with the appropriate hypertension medications. However, according to the most current Star Rating performance measurement, 12.3% of patients with diabetes and hypertension in our pharmacy are not being treated according to the newest JCN 8 guidelines. That is a difference of almost 10%, and this is for only one pharmacy in rural Missouri. What does this mean for all pharmacies and for all health plans?

Updated Star System Rating Needed
With so many moving parts in the healthcare system, sometimes change is slow. How long will it take CMS to modify their Star Rating performance measurements to reflect the new JNC 8 recommendations? This is actually being analyzed right now. Testing is under way within the Pharmacy Quality Alliance (PQA) to assess the validity of this measure with the addition of CCBs and thiazide-type diuretics.

According to Julie Kuhle, RPh, Senior Director of Performance Measurement at PQA, “Testing results for the revised measures are expected by the end of the year.” PQA creates, tests, and maintains many of the quality measures used today, and the Appropriate Treatment of Hypertension in Diabetes is one of them. We will see what happens, but as of today it appears that the JNC 7-based measure will be included in the 2015 Medicare Part D Star Rating calculations. This is just one example of our healthcare system’s evolution.

Clinical guidelines are regularly assessed and improvements are made based on clinical data and outcomes. Changes to population health measurements, such as those included in the CMS Medicare Part D Star Ratings are also evolving to keep up with current clinical recommendations.

When we, as clinicians, strive to improve quality and outcomes, we also have to recognize that change does not always come quickly. However, as our practice models and guidelines evolve, this example shows us that the measurement systems also evolve along with them.




References
  1. Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure Express: the JCN 7 report. JAMA. 2003;289:2560-2572.
  2. American Diabetes Association. Standards of medical care in diabetes-2014. Diabetes Care. 2014;37:S14-S80.
  3. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311:507-520.
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