Using Quality Measures to Address Medication Adherence, Access

Driving better patient medication adherence and access will require establishing a set of clinical quality measures.

By Sara Heath

March 18, 2019 - A clinical quality framework may be an effective path forward for understanding and improving medication access for patients, according to a new report from the Pharmacy Quality Alliance.

The report, which also outlined the key social, financial, and logistical barriers patients face when accessing their medications, asserted that a quality framework could help healthcare leaders develop strategies to overcome those barriers.

“Access to medications is an important part of high-quality, value-based healthcare,” Matthew Pickering, PharmD, PQA’s Senior Director of Research and Quality Strategies, said in a statement. “Improving access, which affects adherence and patient outcomes, requires a focus on the social determinants of health. The framework we have developed holistically defines medication access and identifies gaps in quality measurement that could address the financial and non-financial factors that stand between patients and the medications they need.”

PQA’s work encompassed two phases. First, the organization identified the fundamental barriers patients face when accessing medications. Next, they outlined recommendations for a clinical quality measure set specifically focused on medication access and adherence.

Medication barriers spanned three central areas, the researchers reported. Patients faced organizational, personal, and societal obstacles to accessing their medications.

On an organizational level, the researchers suggested that some clinicians or provider organizations lacked the wherewithal to connect patients with treatments or medications. Some organizations had limited health literacy, meaning they could not identify effective strategies to facilitate medication access.

In some cases, providers had limited prescribing or logistical competencies, leaving patients with little support when accessing a certain drug.

Additionally, some providers had their own biases, especially when treating patients with stigmatized conditions. This led to limited medication access for patients with mental health conditions or illnesses such as HIV/AIDS, the PQA researchers reported.

Patients, too, experienced their own personal limitations when accessing medications. Low patient health literacy and self-efficacy to seek out care were determining factors hindering medication access.

Finally, social issues emerged. Again, stigma was a significant factor, barring patients from accessing medications for stigmatized conditions. Patients seeking Title X services also faced societal pressures.

Social and environmental barriers also limited access for pateints living in rural areas.

Next, the researchers investigated where clinical quality measures already focus on medication access and adherence. Of the 270 medication-related quality measures already used, only 22 focused on medication adherence.

More work is needed to address medication access, the researchers said while outlining recommendations for such measures.

Those measures were related to a cycle of medication access, the team said, which goes as follows:

• Perceived need for medication
• Help seeking
• Care encounter
• Prescribing
• Prescription adjudication
• Prescription dispensing
• Adherence

Frameworks should include screening tools for medication access barriers. Additionally, the development process must include patients and community members and focus on areas outside of medication adherence. After all, patients struggle to access their medications before they get to the point of needing habitual adherence.

For example, frameworks can focus on measures to empower patients during the perceived need and care seeking stages of medication access. If a patient does not seek out care, she cannot receive a prescription. This may require measures associated with patient education and health literacy.

Additionally, frameworks should assess both direct and indirect costs to patients. While patients nearly always face at least a copayment, they also often face indirect medication access costs. This includes the cost of transportation or other logistical considerations connecting them with their care.

Finally, measures should emphasize the importance of pharmacy services in medication management.

This framework is not necessarily a list of quality measures, but instead recommendations for developing such measures, according to Laura Cranston, RPh, the CEO of PQA.

“This important framework provides researchers and measure developers with clear targets for measure development and quality improvement initiatives,” Cranston said. “Given the complexity of medication access, the framework also points toward a medication access core measure set to comprehensively address the barriers patients face. We look forward to supporting the healthcare community in leveraging the framework to develop meaningful, effective measures that benefit patients.”

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