Getting to the Core of CMS Measures

Transcription

1 Pharmacy Technician Education for Association Members By: Joanna Caranante PharmD, BCPS Pharmacy Clinical Coordinator St. Joseph s Hospital Joanna Caranante is currently the Pharmacy Clinical Coordinator at St. Joseph s Hospital in Tampa, FL. She focuses on health-system and hospital based Pharmacy and Therapeutics Committee actions, compliance with Evidence Based Measures, therapeutic initiatives and pharmacy team education and development. Dr. Caranante reports no actual or potential conflicts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this CPE activity. CPE Information: Universal Activity Number: H04-T CPE Hours: 1 contact hour (0.1 CEU) Target Audience: Pharmacy Technicians Activity Type: Knowledge-based Initial release date: 1/1/2014 Planned expiration date: 12/31/2015 The Collaborative Education Institute is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Activity Goal: This activity provides pharmacy technicians with a description of the Centers for Medicare and Medicaid Services (CMS) Core Measures, and their impact on patient care and hospital practice. Disease state information, medications used, and the importance of timing of the various medications, are all discussed for the Core Measure set. Learning Objectives: Upon successful completion of this knowledgebased CPE activity, pharmacy technicians should be able to: 1. Identify the purpose and history of the CMS Core Measures 2. Describe various CMS Core Measures by disease state and topic 3. Explain the medication-related elements of each Core Measure 4. Breakdown the process by which medication delivery impacts CMS Core Measures 5. Summarize both the pharmacy department and technician s role in CMS Core Measures This activity has been developed specifically for pharmacy technicians and is one of 10 activities in the TEAM series. Getting to the Core of CMS Measures What are CMS and Core Measures? The Centers for Medicare and Medicaid Services (CMS) in combination with other groups representing consumers, hospitals, health care practitioners, and regulatory agencies created Hospital Compare. Hospital Compare is a website that provides information on how hospitals provide care to patients. Hospital Compare has information about the quality of care at over 4,000 Medicarecertified hospitals around the country. This publically available website has many benefits. It can help patients make decisions about where to get health care and where will best meet their needs. It can encourage hospitals to improve the quality of care that they provide. 1 The care assessed is the recommended care for certain performance measures including acute myocardial infarction (AMI), heart failure, pneumonia, surgery and other conditions. The information is separated by patient survey results, timely and effective care, readmissions, complications and deaths, use of medical imaging, Medicare payment, and Medicare volume. The Hospital Compare website can be accessed at gov. The first set of core process measures was introduced in 2005 and included acute myocardial infarction, heart failure, pneumonia and surgical care. In 2008, 30-day mortality for AMI, heart failure and pneumonia were added. In 2009, outpatient measures were added. In 2010, 30-day readmission measures for AMI, heart failure and pneumonia were added. In 2012, additional information on surgical outcomes was added. In 2013, venous thromboembolism prophylaxis was added. 1 The current measures include: Acute Myocardial Infarction, Heart Failure, Pneumonia, Surgical Care Improvement Project (SCIP), Children s Asthma Care, Venous Thromboembolism, Stroke, Global Initial Inpatient Population,

2 Emergency Department, and Prevention (Immunization, Tobacco Treatment, Substance Use). 2 This article will review the inpatient adult measures that are medication related and will define how the pharmacy department and pharmacy technicians can contribute to compliance and success of each measure. Key Words Throughout this article the following definitions may be helpful: Keyword Morbidity Mortality Primary prevention Secondary prevention Definition A term for illness. A term for death. Specific practices for the prevention of disease or mental disorders in susceptible individuals or populations. These in health promotion, including mental health; protective procedures, such as communicable disease control; and monitoring and regulation of environmental pollutants. 3 The prevention of recurrences or exacerbations of a disease that already has been diagnosed. This also includes prevention of complications or aftereffects of a drug or surgical procedure. 4 Acute Myocardial Infarction (AMI) The medication-related aspects of the AMI measure include necessary therapies at hospital presentation (aspirin, fibrinolytics) and medications that should be prescribed at hospital discharge (aspirin, angiotensin converting enzyme inhibitors (ACEI)/angiotensin receptor blocker (ARB), betablockers and statins). 2 Medications at presentation The early use of aspirin in patients with AMI has resulted in less adverse events and reduced mortality. 5 Aspirin has shown similar benefits as fibrinolytic therapy. Using aspirin and fibrinolytic therapy together has shown increased benefit. Fibrinolytics are medications that dissolve clots and are commonly referred to as clot-busters. Alteplase is a commonly used fibrinolytic. Aspirin is also used in patients after they have suffered AMI. It has been shown to decrease the risk of additional adverse events and mortality by as much as 20%. Long-term aspirin therapy is strongly recommended in national guidelines for the secondary prevention of additional cardiovascular events. The time to fibrinolytic therapy is important in predicting the outcome for patients with AMI. National guidelines recommend that fibrinolytic therapy is given within 30 minutes of hospital arrival. 6 Medications at discharge Aspirin should be prescribed at discharge as previously mentioned. ACEI have been shown to reduce morbidity and mortality in patients with left ventricular systolic dysfunction (LVSD). 7 LVSD is defined as left ventricular ejection fraction less than 40%. ARBs have also shown benefit in patients who are unable to take ACEI. The use of ACEI/ARB is strongly recommended by national guidelines for patients hospitalized with AMI who have either clinical heart failure or LVSD. 5 Long-term use of beta-blockers has been shown to reduce morbidity and mortality in patients who have had an AMI. 8 It is recommended that patients be discharged on a betablocker after having an AMI. The use of beta-blockers can reduce the risk by as much as 20%. The use of long-term beta-blockers in these patients is strongly recommended by national guidelines. 5 Statin medications (HMG-Co-A reductase inhibitors) have shown benefits in reducing the risk of morbidity and mortality in many patients with cardiovascular disease including patients that have had prior myocardial infarctions. National guidelines strongly recommend the initiation or maintenance of statin drugs for patients hospitalized with AMI, especially those with LDL-cholesterol levels above 100 mg/dl. 5 Heart Failure (HF) ACEI have been shown to reduce morbidity and mortality in patients with heart failure and LVSD. ARBs have also been shown to be an effective alternative in patients that are intolerant to ACEI. ACEI have been strongly recommended by national guidelines. 9 Pneumonia The measure set for pneumonia contains several medication-related topics. These include timing of blood culture before the initial antibiotic received in the hospital and appropriate antibiotic selection for patients with community acquired pneumonia (CAP). 2 Blood cultures are not necessary in all patients, however, when they are performed for certain patients, they should be drawn before treatment with antibiotics. Pretreatment blood cultures are more useful and give better information regarding the pathogen. 10 The IDSA/ATS (Infectious Disease Society of America/ American Thoracic Society) consensus guidelines state Pharmacy TEAM Series 2

3 that Streptococcus pneumoniae is the most common cause of CAP and that treatment that covers atypical pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma pneumoniae) can be associated with improved survival. Several combinations of antibiotics are recommended based on patient risk factors. The correct antibiotic for the selected patient must be given within 24 hours of hospital arrival. 10 The Surgical Care Improvement Project (SCIP) This set of quality measures was first introduced in 2003 as the Surgical Infection Prevention (SIP) measures. It was later changed to the Surgical Care Improvement Project (SCIP) in SCIP is a combination of several national organizations that are committed to improving surgical care and reducing surgical complications. 11 The medication related SCIP measures include antibiotic use (appropriate choice and timing), peri-operative use of beta-blockers for patients currently taking beta-blockers, and venous thromboembolism (VTE) prophylaxis. 2 Surgical prophylaxis with antibiotics has been shown to be most effective when it has been given in time to establish tissue and serum levels at the time of incision. It has been found that the lowest incidence of infection occurs when antibiotics are given within one hour of the incision. A twohour window is allowed for antibiotics that require a longer infusion time (vancomycin and fluoroquinolones). 12 A goal of prophylaxis with antibiotics is to provide benefit to the patient with as little risk as possible. It is important to maintain therapeutic serum and tissue levels throughout the operation. Intraoperative re-dosing may be needed for long operations. However, administration of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient. Prolonged administration does increase the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens. 12 This portion of the measure requires that post-operative antibiotics are discontinued within 24 hours of anesthesia end time (within 48 hours for cardiovascular surgeries). The Society of Thoracic Surgeons (STS) Practice Guideline for Antibiotic Prophylaxis in Cardiac Surgery (2006) indicates that there is no reason to extend antibiotics beyond 48 hours for cardiac surgery and very explicitly states that antibiotics should not be extended beyond 48 hours even with tubes and drains in place for cardiac surgery. 13 Surgical patients receiving beta-blockers prior to surgery should receive their beta-blocker in the perioperative period. The perioperative period is defined as the day prior to surgery through postoperative day two. There have been concerns regarding the discontinuation of beta-blockers in the literature. Small studies have indicated that mortality may be greater in patients who had beta-blocker therapy discontinued. The American College of Cardiology/American Heart Association recommends continuation of beta-blocker therapy in the perioperative period. 14 Venous thromboembolism (VTE) prophylaxis should be initiated within 24 hours prior to surgery to 24 hours after surgery (end of surgery is considered Anesthesia End Time). 2 VTE is one of the most common postoperative complications. The timing and type of VTE prophylaxis (mechanical v. pharmacologic) selected is dependent on various risk factors (type and duration of the surgery and extent of postoperative immobilization). These selections are based on the American College of Chest Physician guidelines. 15 Venous Thromboembolism (VTE) This measure assesses a variety of issues related to VTE including the use of VTE prophylaxis for patients as they are admitted to the hospital, overlap of anticoagulation therapy for patients with VTE, monitoring of patients receiving unfractionated heparin, and discharge instructions for patients starting warfarin therapy. 2 It is estimated that the yearly incidence of deep-vein thrombosis and pulmonary embolism [together referred to as venous thromboembolism (VTE)] is approximately 900,000. Of these, approximately two-thirds of cases are found in patients with recent hospitalization. 16 The Agency for Health care Research and Quality (AHRQ) believes that effective prevention can improve patient safety by decreasing the number of VTE. 17 In a review of evidence-based patient safety practices, the Agency for Health care Research and Quality referred to VTE prophylaxis as the number one patient safety practice for hospitalized patients. 17 A second portion of the VTE measure requires patients with VTE to receive an overlap of parenteral (intravenous or subcutaneous) anticoagulation and warfarin therapy. 2 Patients with an acute VTE should receive parenteral anticoagulation first due to its rapid onset of action. When warfarin is used, it can be initiated on the first day of parenteral anticoagulation and requires several days to be therapeutic. The CHEST guidelines recommend 5 days of overlap between parenteral therapy and warfarin and until the INR is greater than 2 for at least 24 hours. 18 Additional parts of the VTE measure requires patients treated with IV unfractionated heparin to be monitored and adjusted by a nomogram or protocol and to have platelet counts monitored with defined parameters. 2 Studies have shown that unfractionated heparin (UFH) management by weight-based aptt adjusted protocols Pharmacy TEAM Series 3

4 achieve a therapeutic aptt more rapidly than with standard UFH dosing without increasing major bleeding. 19 Heparin-induced thrombocytopenia (HIT) is defined as 50% fall in platelet count from baseline. Platelet counts generally begin to fall five to ten days after the initiation of heparin therapy. Early recognition of HIT is important so that heparin can be discontinued and the risks are minimized. Platelet count monitoring is recommended for all patients treated with UFH. 20 When patients are going home on warfarin for VTE treatment, the measure set requires that they are given discharge instructions that address four specific criteria: compliance, diet, follow-up monitoring, and the potential for adverse drug reactions/interactions. 2 Adverse drug events can include additional clot formation (when enough warfarin is not given) and bleeding events (when too much warfarin is given). Anticoagulation with warfarin is complicated due to monitoring required and diet/drug interaction issues. The Joint Commission National Patient Safety Goal Reduce the likelihood of patient harm associated with the use of anticoagulant therapy also requires that hospitals provide education regarding the same four areas. 21 Stroke The medication-related portions of the stroke measure include VTE prophylaxis, antithrombotic therapy, anticoagulation for atrial fibrillation/flutter, and statin medications. 2 Stroke patients have an increased risk of developing a VTE if they are acutely ill and confined to bed. These patients should get VTE prophylaxis with a low-molecular weight heparin, low-dose unfractionated heparin or fondaparinux. Aspirin alone is not recommended for VTE prophylaxis. Patients in the hospital for acute ischemic stroke should begin antithrombotic therapy by day two of the admission and should be discharged on therapy. Antithrombotic therapies for stroke include aspirin, aspirin/dipyridamole, cilostazol, clopidogrel, and ticlopidine. Patients with atrial fibrillation (AF) or atrial flutter should be on anticoagulation at discharge.oral anticoagulation with warfarin is the best choice of antithrombotic therapy for patients with AF at high risk of stroke. At lower levels of stroke risk, antithrombotic treatment decisions can require a more individualized approach. 22 Patients that are carefully selected and eligible for thromolytic therapy should receive IV t-pa(tissueplasminogen activator or alteplase) at the hospital within three hours of symptom onset. 2 This therapy is aimed at restoring bloodflow. The goal of early reperfusion therapy is to minimize neurologic impairment, long-term disability, and stroke-related mortality. 23 Ischemic stroke patients with LDL greater than or equal to 100 mg/dl should be started on a lipid-lowering medication at hospital discharge. 2 The reduction of LDL cholesterol, through lifestyle modification and drug therapy when appropriate, is recommended for the prevention of myocardial infarction and other major vascular events for patients with CAD (or coronary risk equivalent conditions) according to the National Cholesterol Education Program s Adult Treatment Panel III (NCEP ATP III) Guidelines. 24 Immunization This set of measures addresses preventable diseases with the administration of vaccines. Patients greater than 65 years old and between 5 and 65 years old with risk factors should receive pneumococcal vaccine. Patients greater than six months old should receive influenza vaccine each season. 2 Pneumococcal disease is caused by Streptococcus pneumoniae bacteria and is the leading cause of preventable illness and death in the United States. Some people are at greater risk than others to get pneumococcal disease. People at greater risk include 65 years and older, very young, people with certain health problems, people with a weakened immune system and smokers. Pneumococcal disease can lead to serious infections of the lungs (pneumonia), blood (bacteremia), and the covering of the brain (meningitis).pneumococcal pneumonia kills about one out of 20 people who get it. Bacteremia kills about one person in five, and meningitis about three people in ten. 25 Influenza ( flu ) is a contagious disease that spreads around the United States during the winter season (between October and May). Flu is caused by the influenza virus and is spread by close contact (coughing and sneezing). Children are at the highest risk of getting the flu. Symptoms can include fever/ chills, sore throat, muscle aches, fatigue, cough, headache and runny or stuffy nose. Every year in the United States, many people are hospitalized from flu and thousands of people die from flu. The flu vaccine can help protect from flu and can prevent spreading from person to person. 26 How can the pharmacy department and pharmacy technicians contribute to the success of these Core Measures? 1. By providing timely access to medications. Keeping automated dispensing cabinets stocked appropriately and recognizing medications that are important components of these care sets. The pharmacy department and pharmacy technicians can impact many of the core measures through timely dispensing. 2. By recognizing appropriate medications for disease states at transitions of care. When reviewing medication histories during admission or discharge medication lists, Pharmacy TEAM Series 4

5 the pharmacy department and pharmacy technicians can ensure that proper therapies are initiated based on the disease state. 3. By counseling patients appropriately on the importance of the medication. When reviewing medication histories or dispensing medications to patients, the pharmacy department and pharmacy technicians can provide valuable information regarding the use of each medication in relationship to the disease state. References: 1. What-Is-HOS.html?AspxAutoDetectCookieSupport=1 Accessed July 1, ge&pagename=qnetpublic%2fpage%2fqnettier4&c id= Accessed July 1, Primary Prevention at the US National Library of Medicine Medical Subject Headings (MeSH) 4. Secondary Prevention at the US National Library of Medicine Medical Subject Headings (MeSH) 5. O Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr, Chung MK, de Lemos JA, et al ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol2013;61: Jneid H, Anderson JL, Wright RS, Adams CD, Bridges CR, Casey DE Jr, et al ACCF/AHA focused update of the guideline for the management of patients with unstable angina/non ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol2012;60: Flather MD, Yusuf S, Kober L et al. Long-term ACEinhibitor therapy in patients with heart failure or left-ventricular dysfunction: a systematic overview of data from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet. 2000;355(9215): Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in heart disease. I. Treatments following myocardial infarction. JAMA. 1988; 260(14): Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al, writing on behalf of the 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult Writing Committee focused update: ACCF/AHA guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am CollCardiol. 2009;53: Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis March 1;44Suppl 2:S improvement_project/ Accessed July 1, Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, Infect Control HospEpidemiol. 1999;20: Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of Thoracic Surgeons Practice Guideline Series: Antibiotic prophylaxis in cardiac surgery, Part I: Duration, Ann Thoracic Surg2006; 81: Fleisher LA, Beckman JA, Brown KA, Calkins H, et al. ACC/AHA 2007 Guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). J Am CollCardiol2007; 50: e Guyatt G, Akl E, Crowther M, Gutterman D, Schuünemann H. Executive summary: antithrombotic therapy and prevention of thrombosis. The Ninth ACCP edition: ACCP evidence-based clinical practice guidelines. Chest 2012; 141;7S-47S. PMID: Heit J. The epidemiology of venous thromboembolism in the community. Arteriosclerosis, Thrombosis and Vascular Biology 2008;28(3): Shojania KG, Duncan BW, McDonald DM, et al. (Eds.). (2001). Making health care safer; A critical analysis of patient safety practices (Evidence Report/Technology Assessment No. 43). Prepared by the University of California at San Francisco-Stanford Evidenced-based Practice Center under Contract no (AHRQ Publication NO.01-E058). Rockville, MD:Agency for Health care Research and Quality. 18. Guyatt, G.H., Akl, E.A., Crowther, M., Gutterman, D., Schunemann, H. Antithromboitic Therapy and Prevention of Thrombosis, 9th edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. CHEST 2012; 141(2) (Supp):7S-47S. 19. Raschke RA, Reilly BM, Guidry JR et al. The weightbased heparin dosing nomogram compared with standard care nomogram. Ann Intern Med Nov 1; 119(9): Linkins, LA, Dans A.L., Moores L.K., Bona R., Davidson B.L., Schulman, S., Crowther, M. Treatment and Prevention of Heparin-Induced ThrombocytopeniaAntithrombotic Therapy and Prevention of Thrombosis,9th ed: American College of Chest PhysiciansEvidence-Based Clinical Practice Guidelines CHEST 2012; 141(2)(Suppl):e495S e530s Chapter_Jan2013_HAP.pdf Accessed July 1, 2013 Pharmacy TEAM Series 5

6 22. You J.J., Singer, D.E., Howard, P.A., Lane, D.A., Eckman, M.H., Fang, M.C., Hylek, E.M., Schulman, S., Go, A.G., Hughes, M., Spencer, F.A., Manning, W.J., Halperin, J.L., Lip, G.Y. Antithrombotic Therapy for Atrial Fibrillation. Antithrombotic Therapy and Prevention of Thrombosis,9th ed: American College of Chest PhysiciansEvidence-Based Clinical Practice Guidelines CHEST 2012; 141(2)(Suppl):e531S e575s 23. Lansberg, M.G., O Donnell, M.J., Khatri, P., Lang, E.S., Nguyen-Huynh, M.N., Schwartz, N.E., Sonnenberg, F.A., Schulman, S., Vandvik, P.O., Spencer, F.A., Alonso- Coello, P., Guyatt, G.H., Aki, E.A. Antithrombotic and Thrombolytic Therapyfor Ischemic Stroke. Antithrombotic Therapy and Prevention of Thrombosis,9th ed: American College of Chest PhysiciansEvidence-Based Clinical Practice GuidelinesCHEST 2012; 141(2)(Suppl):e601S e636s 24. Grundy, S. M., J. I. Cleeman, C. N. Merz, H. B. Brewer, Jr., L. T. Clark, D. B. Hunninghake, R. C. Pasternak, et al. Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. [In eng]. Circulation 110, no. 2 (Jul ): ppv.html#what Accessed July 1, flu.html#why Accessed July 1, Pharmacy TEAM Series 6

7 Getting to the Core core of CMS measures Measures ASSESSMENT QUESTIONS: 1) What is the website where hospitals can be compared to each other? A) Hospital Compare B) Compare my health C) CMS Measures D) Medicare Hospitals 2) Which medication should be initiated after a patient has an acute myocardial infarction? A) Aspirin B) ACEI/ARB C) Aspirin and ACEI/ARB D) None of the above 3) True/False SCIP is the acronym for Surgical Care Improvement Project. 4) Why are antibiotics given prior to surgery? A) Prevent infection B) Make the surgery easier to perform C) Prevent the surgery from being necessary D) Prevent the need for VTE prophylaxis 5) Which type of medication should be continued during the perioperative period? A) Aspirin B) ACEI C) Beta-blockers D) ARB C) They achieve therapeutic aptt quicker and increase major bleeding D) They achieve therapeutic aptt slower and increase major bleeding 8) Which immunizations are required by the core measures? A) Pneumococcal and influenza B) Hepatitis B and hepatitis A C) Hepatitis B and influenza D) Hepatitis A and pneumococcal 9) Influenza is common during which season? A) Fall B) Winter C) Spring D) Summer 10) What can the pharmacy department do to help make these core measures a success? A) Provide timely access to medications. B) Recognize appropriate medications for disease state at transitions of care. C) Counsel patients appropriately on the importance of the medication. D) All of the above 6) What are the key components to warfarin education A) Compliance, diet, monitoring, potential for adverse drug reactions B) Diet, monitoring, potential for adverse drug reactions C) Compliance, diet, monitoring D) Compliance, monitoring, potential for adverse drug reactions 7) Why are heparin nomograms important for dosing IV heparin drips? A) They achieve therapeutic aptt quicker without increasing major bleeding B) They achieve therapeutic aptt slower without increasing major bleeding CPE INSTRUCTIONS: Pharmacy technicians must read this activity and successfully complete the exam (70% pass rate) and evaluation prior to December 31, 2015 using the following instructions: Login to MY PORTFOLIO on On the right of the title of this article, click on GO TO EXAM Upon successful completion of the exam, you will see a page with explanations to the exam questions. After reading through this feedback, scroll to the bottom of the page and click GO TO EVALUATION Complete the evaluation and click SUBMIT You can obtain your CPE Statement of Credit at If you have any questions about this process, please contact Cindy Smith, csmith@gotocei.org, Pharmacy TEAM Series 7