Why pharmacy practice needs quality indicators

Introduction

Community-based pharmacists are playing a larger role in Canada’s primary health care system, increasingly recognized for their contributions to optimizing medication use and improving patient outcomes through activities such as prescribing and chronic disease management. Consistent evidence has demonstrated that pharmacist-led interventions can improve adherence, enhance transitions of care, reduce the use of inappropriate medications, and improve outcomes. ¹ Yet, despite our growing contributions, the profession remains virtually completely ignored in health system planning and performance measurement. One commonly cited limitation of the practice of pharmacy by health system leaders is the inconsistent quality and lack of insight into the practice of pharmacy by the health system, which would allow integration. Stated another way, health policy-makers are now seeking to improve quality of care—if we can’t prove that we improve it, we won’t be part of system change. Fundamental to this, if we don’t measure it, we can’t claim to improve health care quality and will miss out on retaining and/or expanding our role in the changing delivery of health care.

Policy-makers, payers, and patients lack standardized ways to assess the quality of pharmacy practice, resulting in missed opportunities to demonstrate value, benchmark performance, and drive continuous improvement. Quality measurement is central to modern health care systems around the world. ² Validated quality indicators (QIs) are routinely used to monitor the safety, effectiveness, and patient-centredness of care. In community pharmacy, however, systematic measurement remains underdeveloped or, in many cases, completely lacking. The decentralized nature of community pharmacy practice, the absence of integrated data systems, and a historical focus on dispensing have limited the adoption of previously proposed QIs.^3,4 Consequently, the quality of pharmacy services is often inferred through isolated process measures, such as overuse of medication reviews or narrative reporting (i.e., outputs rather than outcomes). ⁵ More importantly, this limits the ability to directly link pharmacy practice at a health system level to patient outcomes.

To advance the profession, pharmacy requires a robust framework of QIs that allow for a culture of quality improvement in community pharmacy. We propose the urgent need for and development of a national system of QIs specific to pharmacy practice. These measures would capture the processes and outcomes most directly influenced by pharmacists.

What are QIs?

QIs are standardized, evidence-based measures used to evaluate the quality of health care services across domains such as safety, effectiveness, efficiency, timeliness, and patient-centredness. Brooke first proposed this concept in the 1990s. ⁶ QIs are designed to help understand processes and measure if they are appropriately delivered and whether they improve outcomes at both the patient and system/population level. In addition, they provide a common set of metrics to allow for comparison within a unit (system or geography) for providers, institutions, and even regions. They have become standards of practice in hospitals, primary care settings, and long-term care facilities and are often led or supported by government agencies.

QIs can be categorized into 3 broad types (Figure 1):

Figure 1.

Structure, process, and outcome quality indicator categories

1. Structure indicators: Assess the resources, organizational features, or system infrastructure that enable quality care (e.g., presence of electronic health records)

2. Process indicators: Measure whether evidence-based practices are being delivered as intended (e.g., proportion of patients receiving recommended screenings or guideline-suggested therapy)

3. Outcome indicators: Capture the effects of care on patients, including clinical outcomes, adverse events, or health-related quality of life

The importance of QIs lies not only in benchmarking but also in their use for audit and feedback (A&F) interventions. ⁷ This process, which provides practitioners or institutions their own data on their performance relative to standards or peers, has been strongly shown to improve quality. These interventions using QIs can motivate behaviour change and drive quality improvement. Evidence from multiple health professions shows that audit and feedback interventions, anchored in reliable and actionable indicators, will lead to measurable improvement. Despite their potential, pharmacy has historically underused QIs. While organizations such as the Pharmacy Quality Alliance in the United States ⁸ and pilot projects in Canada have demonstrated the feasibility of QI measurement, ⁹ the field lacks consensus on which indicators best capture the unique value of pharmacists.

Why are QIs important for pharmacy practice?

In Canada, policy-makers are increasingly demanding evidence of value and quality of health care delivery, with provinces such as Alberta and Ontario embedding quality frameworks into health system planning. For example, the Alberta Quality Dimensions for Health highlight domains such as safety, effectiveness, and appropriateness as benchmarks for all health services, ¹⁰ while Ontario’s health system quality agenda emphasizes accountability and measurable outcomes. ¹¹ However, these provincial frameworks reflect only part of the broader international conversation about what constitutes “quality.” The recently proposed Quintuple Aim for Health Care Improvement expands on the widely adopted Triple and Quadruple Aim models by underscoring 5 interconnected goals ⁴ :

• Improving population health

• Enhancing patient experience

• Reducing costs

• Supporting workforce well-being

• Advancing health equity

By positioning equity as a distinct and measurable aim, the Quintuple Aim reinforces the importance of going beyond safety and effectiveness to also demonstrate how health services—including pharmacy practice—address disparities and improve outcomes for marginalized groups. ⁴ Without equivalent QIs in pharmacy practice, it remains difficult to show alignment with Canada’s provincial priorities or global frameworks for health system improvement.

Furthermore, the absence of a QI framework to guide pharmacy practice in Canada has resulted in the delivery of clinical services that are often measured by volume rather than by outcomes. This has contributed to care delivery models that have limited effectiveness. This issue is particularly evident in the case of medication reviews, which are among the most common clinical services delivered by community pharmacists in Canada. ¹ Medication reviews are typically evaluated by the number completed or the number of drug-related problems identified. Although widely implemented, the literature shows that medication reviews, as currently structured, do not reliably improve patient or system outcomes.^12,13 A meta-analysis of 31 randomized controlled trials demonstrated that medication reviews produced no effect on clinical outcomes such as hospital admissions, health care use, quality of life, or mortality. ¹³ One explanation for this is pharmacists’ selection of a patient population who may not derive the greatest benefit from medication reviews (the “easier” patients). Recently, Al Hamarneh et al. ¹⁴ showed in a study of 20,000 patients with diabetes, using point-of-care testing as part of a medication review, that pharmacists selected patients with an average A1c of 7.0, indicating that only well-controlled patients are being enrolled. Similarly, Torabi et al. ⁹ recently showed that Ontario pharmacists conducted medication reviews in only 7.8% to 16.2% of eligible patients within 7 days of hospital discharge.

The importance of QIs lies not only in benchmarking but also in their use for A&F interventions. This process, which provides practitioners or institutions their own data on their performance relative to standards or peers, has been strongly shown to improve quality. These interventions using QIs can motivate behaviour change and drive quality improvement. Evidence from multiple health professions shows that A&F interventions, anchored in reliable and actionable indicators, will lead to measurable improvement. Despite their potential, pharmacy has historically underused QIs. While organizations such as the Pharmacy Quality Alliance in the United States and pilot projects in Canada have demonstrated the feasibility of QI measurement, the field lacks consensus on which indicators best capture the unique value of pharmacists.

For these reasons, clinical service delivery in pharmacy practice urgently needs a redesign to focus on QIs. Rather than an emphasis on the quantity of interventions delivered, redesigned services should be assessed against outcomes that matter to patients and health systems, such as improved disease control, achievement of guidelines-based QIs, or enhanced patient quality of life. These indicators would provide both accountability and actionable feedback for pharmacists while aligning pharmacy services with the dimensions of quality already prioritized by policy-makers in Canada.

In Alberta, we have launched several chronic disease management programs that are intended to take medication reviews to the next level. ¹⁵ These programs have taken relevant national guidelines and developed electronic tools for pharmacists to apply these guidelines. We are using the national guidelines recommendations as QI outcomes for these programs (Table 1).

Table 1.

Examples of guideline-based quality indicators embedded within chronic disease management programs

Chronic disease	Examples of quality indicators
Chronic obstructive pulmonary disease	1. Percentage of people with a clinical diagnosis of COPD who had their diagnosis confirmed by postbronchodilator spirometry 16 2. Individualized comprehensive management plan: Percentage of people with COPD who had a current individualized comprehensive management plan relevant to their stage of disease based on an annual clinical 16 3. Corticosteroids for acute exacerbations: Percentage of people with moderate-to-severe COPD and a previous COPD-related hospitalization or emergency room visit who received systemic corticosteroids during their last exacerbation 16 4. Influenza vaccination received: Percentage of people with COPD who received an influenza immunization in the preceding flu season 16 5. Pulmonary rehabilitation referral: Percentage of eligible people with moderate-to-severe COPD (GOLD grades for severity of airflow limitation 2–4) who have ever been referred to a multidisciplinary pulmonary rehabilitation program meeting current standardized guidelines 16 6. Smoking cessation intervention received: Percentage of people with COPD who are current smokers who received a smoking cessation intervention (e.g., counselling, pharmacotherapy) in the past year 16 7. Smoking cessation success: Percentage of people with COPD who smoked and who quit for at least 1 month in the past year 16 8. Advance care directives discussed: Percentage of people with advanced COPD who discussed and had documented health care directives (or advanced directives) and goals of care with their health care professional 16 9. Pharmacotherapy: Percentage of people with COPD given a new inhaler, spacer, or nebulizer who were trained by a qualified health care provider to use the device 16 10. Pharmacological treatment: Percentage of people with stable COPD which have ≤1 exacerbations per year, CAT score ≥10, and a mMRC dyspnea scale score ≥2 should have initial management of LABA+LAMA agent 17 11. Comprehensive assessment: Percentage of people with COPD whose degree of COPD-related disability has been evaluated within the past 12 months 18 12. Comprehensive assessment: Percentage of people with COPD whose risk of acute exacerbation of COPD has been reviewed within the past 12 months 18 13. Pharmacologic management of stable COPD: Percentage of people with COPD who receive inhaled corticosteroid monotherapy 18 14. Long-term oxygen therapy: Percentage of people with stable COPD and at least 1 indication for long-term oxygen therapy who receive long-term oxygen therapy 18
Diabetes	1. Diabetes education: The proportion of people with diabetes who are receiving personalized advice on physical activity 19 2. HbA1c testing: Percentage of patients with 1 or more HbA1c tests annually 20 3. LDL-C testing: Percentage of patients with at least 1 LDL cholesterol test annually 20 4. Eye examination: Percentage of patients who received a dilated eye examination or evaluation of retinal photography by an ophthalmologist 20 5. HbA1c control: Percentage of patients with most recent HbA1c level >7.0% 20 6. LDL-C control: Percentage of patients with most recent LDL cholesterol >2.0 mmol/L 20 7. Lower extremity amputation: Percentage of patients receiving at least 1 foot examination annually 20 8. Screening for nephropathy: Percentage of patients with at least 1 test for microalbuminuria during the measurement year or who had evidence of medical attention for existing nephropathy 20 9. Cardiovascular mortality: Prevalence of cardiovascular disease among people with diabetes over time 19 10. Screening for neuropathy: Percentage of patients with diabetes neuropathy screening within specified time frame 19 11. Identifying and assessing mental health needs: Percentage of people with type 2 diabetes who were screened for psychological distress and mental health disorders within the past year 21 12. Promoting self-management skills: Percentage of people with type 2 diabetes who participate in a self-management plan 21 13. Cardiovascular protection: Percentage of people with type 2 diabetes who receive care that incorporates an individualized cardiovascular risk reduction approach 21
Osteoarthritis	1. Measurement to support improvement: Percentage of people with osteoarthritis who identify a significant change in their monitored symptom(s), or a new symptom or a new goal for their care plan, and who review their comprehensive assessment of needs and their care plan with their clinician 22 2. Patient education: Percentage of people with osteoarthritis who receive education in an accessible format on osteoarthritis and its management 22 3. Patient education: Percentage of people with osteoarthritis who report a high level of success in coping with and self-managing their condition 22 4. Patient self-management plan: Percentage of people with osteoarthritis who have a documented self-management plan 22 5. Patient self-management plan: Percentage of people with osteoarthritis who identify a significant change in their monitored symptoms(s), or a new symptom or goal for their care plan, and who review their self-management plan with their clinician 22 6. Therapeutic exercise: Percentage of people with osteoarthritis who participate in progressive neuromuscular training, muscle strengthening, and aerobic exercise programs 22 7. Physical activity: Percentage of people with osteoarthritis who receive information and support to participate in daily physical activity from a clinician 22 8. Physical activity: Percentage of people with osteoarthritis who complete a weekly minimum of 150 minutes of moderate-to-vigorous physical activity 22 9. Weight management: Percentage of people with osteoarthritis whose waist circumference or body mass index is documented in their medical chart 22 10. Weight management: Percentage of people with osteoarthritis who are overweight or obese and who receive a documented weight management strategy 22 11. Pharmacologic symptom management: Percentage of people with osteoarthritis who are prescribed pain-relieving medication and who also receive non-pharmacologic treatments 22 12. Pharmacologic symptom management: Percentage of people with osteoarthritis who are prescribed pain-relieving medication and who have a documented discussion of risks and benefits of their medication with their primary care clinician 22 13. Referral to a clinician with additional skills in osteoarthritis management: Percentage of people with osteoarthritis who are referred to a clinician with additional skills in osteoarthritis management when clinically indicated 22 14. Referral to a clinician with additional skills in osteoarthritis management: Percentage of people with osteoarthritis whose primary care clinician received and shared with them a recommended plan for treatment from the clinician with additional skills in the management of osteoarthritis after their visit 22 15. Referral for consideration of joint surgery: Percentage of people with osteoarthritis who report that their symptoms are not sufficiently controlled and are negatively impacting their quality of life, who are referred to an orthopedic surgeon for consideration for joint surgery 22 16. Referral for consideration of joint surgery: Percentage of people with osteoarthritis referred for consideration of joint surgery who have documentation of having received non-surgical management prior to their referral 22
Cardiovascular disease 15	1. Percentage of adult patients who have weight and height or waist circumference recorded on the chart23 -25 2. Percentage of adult patients who have alcohol consumption recorded on the chart23 -25 3. Percentage of adult patients who have smoking status recorded on the chart23 -25 4. Percentage of patients who are current smokers and have smoking cessation counselling or a referral for counselling recorded on the chart23 -25 5. Percentage of healthy patients (no previous cardiovascular risk) 40 to 80 years of age (men) or 50 to 80 years of age (women) who have lipid testing at least every 5 years recorded on the chart23 -25 6. Percentage of adult patients who have had a visit to their usual primary care provider’s office in the previous 3 years whose blood pressure was recorded on the chart23 -25 7. Percentage of patients older than 40 years of age (men) and older than 50 years of age (women) for whom a global risk assessment (e.g., Framingham model) has been recorded on the chart23 -25 8. Percentage of patients with a systolic blood pressure of 140 mmHg to 159 mmHg or diastolic blood pressure of 90 mmHg to 99 mmHg who have a follow-up visit in a 6-month period recorded on the chart23 -25 9. Percentage of patients with an average systolic blood pressure of greater than 160 mmHg and/or a diastolic blood pressure greater than 100 mmHg, as determined on at least 3 separate visits, who have a diagnosis of hypertension recorded on the chart23 -25 10. Percentage of adult patients whose blood pressure is 180/110 mmHg or greater, or 140/90 mmHg or greater and who have diabetes, chronic renal disease, or target organ damage, who have a record on the chart of a second visit for blood pressure within 2 months of the first elevated blood pressure visit23 -25 11. Percentage of adult patients whose blood pressure is 180/110 mmHg or greater, or 140/90 mmHg or greater and who have diabetes, chronic renal disease, or target organ damage on a second visit, who were labelled as hypertensive on the chart23 -25 12. Percentage of patients with an average systolic blood pressure of 160 mmHg or greater, or a diastolic blood pressure of 100 mmHg or greater with a recommendation for drug therapies recorded on the chart23 -25 13. Percentage of patients with an average diastolic blood pressure of 90 mmHg or greater with a recommendation for drug therapies recorded on the chart if target organ damage is present or if they have independent cardiovascular risk factors (elevated systolic blood pressure, cigarette smoking, abnormal lipids, family history of premature cardiovascular disease, truncal obesity, sedentary lifestyle)23 -25 14. Percentage of patient visits (for blood pressure follow-up) for those with hypertension whose blood pressure is above target (140/90 mmHg, or 130/80 mmHg for patients with diabetes or renal disease) with a plan of care for hypertension recorded on the chart that includes a change in dose or regimen of medications, and/or repeated education regarding lifestyle modification, and/or planned reassessment23 -25 15. Percentage of adult patients with hypertension and diabetes who have a measure of urinary protein excretion (e.g., 24 h urine, dipstick for microalbuminuria, etc.) on the chart23 -25 16. Percentage of patient visits for congestive heart failure during which weight was recorded in the chart23 -25 17. Percentage of adult patients with 1 or more of the following who have lipid testing recorded on the chart every 2 years: diabetes mellitus; hypertension and/or risk factors, such as smoking or abdominal obesity and/or strong family history of premature ischemic heart disease; or evidence of symptomatic or asymptomatic coronary artery or vascular disease23 -25 18. Percentage of patients with hyperlipidemia for whom a therapeutic target, based on their global risk assessment and lipid profile, has been recorded on the chart23 -25 19. Percentage of patients with hyperlipidemia who are at high risk for ischemic heart disease, for whom it has been recorded on the chart that pharmacologic treatment was recommended immediately, concomitant with dietary and lifestyle changes23 -25 20. Percentage of patients identified as hypertensive for longer than 12 months whose most recent blood pressure was at target: a. Non-diabetic patients having a systolic blood pressure of less than 140 mmHg and a diastolic blood pressure of less than 90 mmHg b. Diabetic patients or patients with renal disease having a systolic blood pressure of less than 130 mmHg and a diastolic blood pressure of less than 80 mmHg c. Patients with proteinuria having a systolic blood pressure of less than 125 mmHg and a diastolic blood pressure of less than 75 mmHg23 -25
	21. The percentage of patients with ischemic heart disease who are taking acetylsalicylic acid or have a contraindication to, or side effects from, acetylsalicylic acid23 -25 22. The percentage of patients with ischemic heart disease who have had a myocardial infarction and are taking a beta-blocker or have a contraindication to, or side effects from, a beta-blocker23 -25 23. The percentage of patients with ischemic heart disease who are on an angiotensin-converting enzyme inhibitor, or have a contraindication to, or side effects from, an angiotensin-converting enzyme inhibitor23 -25 24. Percentage of patients with left ventricular systolic dysfunction (ejection fraction of less than 40%), whether symptomatic or asymptomatic, who are taking an angiotensin-converting enzyme inhibitor or an angiotensin receptor II blocker, or have a contraindication to, or side effects from, both an angiotensin-converting enzyme inhibitor and an angiotensin receptor II blocker23 -25 25. Percentage of patients with left ventricular systolic dysfunction (ejection fraction of less than 40%) who are taking a beta-blocker or have a contraindication to, or side effects from, beta-blockers23 -25 26. Percentage of patients who receive self-management education23 -25

CAT, COPD assessment test; COPD, chronic obstructive pulmonary disease; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HbA1c, hemoglobin A1c; LABA+LAMA, long-acting beta agonist and long-acting anticholinergic; LDL-C, low-density lipoprotein cholesterol; mMRC, modified Medical Research Council.

Conclusion

Health policy-makers are looking for ways to improve health care quality. Pharmacists, pharmacy organizations, and pharmacy practice researchers need to take this opportunity and embed QIs into their systems and research. Pharmacists can achieve many of the guideline-suggested QIs, so much so that these might be termed “Pharmacy-Sensitive Quality Indicators” (more on this in our next editorial). ■