Missing metrics: Putting CMM-specific measures in place

How do we demonstrate the value of CMM? By measuring it, of course. But we’re missing some critical tools.

Key elements of comprehensive medication management have been in place for years. Recent research has defined standards of care, structure and process for CMM programs, but the development and validation of tools to measure and assess CMM quality and outcomes metrics are still nascent.

To demonstrate value, we must identify and apply valid and reliable measures. Over the past year, the Evidence-Based Resources Subgroup of the GTMRx Practice and Care Delivery Transformation Workgroup has been reviewing the evidence and making recommendations around CMM-specific measures. We’ve submitted our formal recommendations for publication, but I want to talk about some of the broader issues related to CMM measures—especially fidelity. Fidelity of CMM services is critical to sustainable and measurable success.

Fidelity in practice, structure and process

Reliable attribution of outcomes to CMM interventions requires consistency of CMM delivery.

Fidelity of practice is essential if we are to reduce implementation variability and truly standardize CMM for evaluation purposes. What we call CMM in New York should look like what we call CMM in North Carolina or Minnesota. CMM-sensitive quality measures must be established and validated. We cannot continue to rely solely on medication-related metrics not developed for CMM. Across health care, we need broad-based groups of measures to reflect the whole patient to replace the current approach: single measures with a relatively narrow focus. This needs to be an important consideration for CMM.

In terms of fidelity of structure, there is an evaluation tool that was published last year.¹ The CMM Practice Management Assessment Tool, or PMAT, looks at five CMM practice management domains:

• Organizational support
• Care team engagement
• Care delivery processes
• CMM program evaluation
• Ensuring consistency and quality of care

The tool is housed at optimizingmeds.org website, which is maintained by the UNC Eshelman School of Pharmacy Center for Medication Optimization.

Another tool developed as part of the CMM Fidelity Assessment System evaluates process: the CMM Patient Care Process Self Assessment (CMM PCPSA).^2,3 It combines a five-point scale and open-ended questions that assess the five essential functions of CMM. The answers to the survey are based upon the individual’s reflection of recent CMM patient care visits. This, too, should be completed at baseline and routinely thereafter for the evaluation of CMM patient care process activities.

Where are we now?

At a recent GTMRx Executive Roundtable, Susan Dentzer asked me to rate where we are today, with 1 being “no meaningful measures around CMM” and 10 being “the best, most robust set of measures.”

I had to answer with “3.”

Our survey of current literature found few measures developed specifically for CMM, especially ones that focus on outcomes. We hope to change that. And yes, medication sensitive measures have long been incorporated in quality constructs and in contracting. But many of them haven’t been fully evaluated in the context of CMM.

To move that “3” closer to a “10,” we need agreement about which globally important outcomes are a good reflection of a value of care as it relates to medication-related outcomes. We also must recognize that one size will never fit all: Global outcomes will always be part of the picture, but there will be specific needs unique to each practice environment.

We still have some distance to go.

Identifying the gaps

Perhaps the most significant gap we identified is a general failure to align with patient and caregiver needs. We like to say that value is in the eye of the patient, yet many of the measures we use don’t reflect that. According to American Institutes for Research principles, patient-centered measures should be patient driven, holistic, transparent, comprehensible, and probably most importantly, co-created with patients and caregivers. I think we can all agree there’s been very little co-creation for quality and outcomes measures.

We also identified a lack of well-defined outcome measures that reflect true outcomes (rather than surrogate end points); this is especially true for drug-related outcomes.

Reliable cost-of-care measures, including hard-dollar outcomes, must be better defined.

We need more outcome measures with high attribution to CMM. Attribution is the holy grail of quality and outcome measures. We always are looking to parse out attribution to justify additional resources, including clinical pharmacists. However, I’m convinced we need to establish the value of interprofessional team-based care. If CMM services are an essential component of that team approach, then CMM must be included in the overall model. If at the end of the day, we can demonstrate better care at a lower cost—or at least a better value—with an improved patient and team experience, then this model, including CMM, will be supported.

Moving forward: Collaborate

Clinicians and researchers need to continue to collaborate to define broadly applicable measures of CMM related quality and outcomes. It requires true collaboration, because most clinicians are not in the position to do this research. The researchers will need to work with the clinicians to demonstrate value in real-world practice environments. And if we want CMM to be widely adopted, we must establish that it works in the real world.

This blog is a follow-up to the GTMRx Executive Roundtable on June 24, 2021.

1. Pestka, DL, Frail, CK, Sorge, LA, et al. Development of the comprehensive medication management practice management assessment tool: A resource to assess and prioritize areas for practice improvement. J Am Coll Clin Pharm. 2020; 3: 448– 454. https://doi.org/10.1002/jac5.1182
2. Blanchard C, Livet M, Ward C, Sorge L, Sorensen TD, McClurg MR. The Active Implementation Frameworks: A roadmap for advancing implementation of Comprehensive Medication Management in Primary care. Res Social Adm Pharm. 2017 Sep-Oct;13(5):922-929.: 10.1016/j.sapharm.2017.05.006.
3. Pestka et al. 2020 op. cit.