Pharmacy 483:QI and DUE in Pharmacy Practice Steve Riddle, BS Pharm, BCPS QI and Medication Utilization Lead HMC Pharmacy February 24, 2004
Acute Myocardial Infarction • HA, 52yo male admitted via ER with severe, “crushing chest pain”, ST elevation with positive enzyme elevations. • What should be done for this patient?
How do we assess quality? • Quality Assurance (QA):quality assurance is any systematic process of checking to see whether a product or service is meeting specified requirements • Implies “maintenance of standard” • Quality Improvement (QI) • Focus is on improvement of product or service or process
Continuous Quality Improvement (CQI) “Doing things right first time" • Implies that there is only one way to do something and that good quality care is static and unchanging. • It is essential to strive for continuous quality improvement and not to assume that because things are "done right first time" they cannot be done better.
Three Categories of Quality Improvement • Eliminating quality problems • Remove unsafe on ineffective agents from formulary • Facilitating use of most appropriate agent • Reducing order-drug turnaround times (ie, automation) • Reducing costs while maintaining or improving quality • Optimize drug acquisition cost: contract negotiations, Group Purchasing Organizations (GPOs) • Therapeutic substitution initiatives (ex., PPIs) • Generic utilization • Expanding customer expectations • Development of innovative products and services to attract customers (ie, CDTM, mail order)
QI Methodology Many QI theories or methods. Most share key steps…. • Identify What are you improving? • Analyze Understand the problem(s) • Develop Hypothesize solutions/changes • Test or Implement Put it into practice • Assess Outcomes What worked? • Sustain Hold the gains • Spread Broaden scope of gains
AMI Treatment:3 QI Examples In Pharmacy . #1 Disease State Management #2 Pharmacologic Class Review #3 Drug Use Evaluation (DUE)
AMI Drug Treatment:Assessing Quality Indicators • What are goals? • Current Clinical Recommendations (AHA & NCEP Guidelines) • Benchmarking (CMS Data, UHC) • Review patient data for EBM drug indicators • Retrospective: Disch Dx (ICD-9 Codes), • Prospective (”Real Time”) • Identify areas for improvement • Where are major deficiencies?
Quality of Care for AMI:Disease State Management Focus on provision of key elements of care that optimize outcomes • Interventions (Arteriogram, PCTA, CABG) • Labs and Diagnostic Eval. (ECG, enzymes, Echo, EF) • Messages (Life Style Modification, Smoking Cessation, Medication Adherence) • Drug Therapy (Thrombolytics, Heparin, GP-2B3A inhibitors, ASA, ACEIs, Beta-Blockers, Statins) • Timeliness of therapy (door-to-drug)
HMC Rx Rates : Secondary Prevention in AMI 100 86 86 80 64 Percent of Patients 60 50 40 18 20 0 ASA Beta blocker ACEI Statin Smoking Cessation Report from 10/2000, UHC Benchmarks
Provider lack of awareness of benefits Inconsistencies in prescribing habits Lack of use of current prescribing aids Complex processes education/awareness of providers Simplify processes order sets, clinical pathways Designate specific responsibilities Clinical Care Coordinator or pharmacist on clinical team Use data (ie, daily admit printouts) AMI Treatment: Indicated Drugs Under Utilized?ProblemsSolutions
Pharmacist Role • Collaborate in development of practice guidelines • Committee involvement • Standing order and clinical pathway development • Influence prescribing patterns • Daily rounding or clinic interactions • Conduct educational programs for residents • Provide feedback to prescribers around specific drugs • “Counter-detailing” • Perform direct patient care roles • Anticoagulation service • Collaborative disease management protocols • Patient education programs
HMC Rates for Secondary Prevention in AMI 100 94 94 100 86 80 74 60 Percent of Patients 40 20 0 ASA Beta blocker ACEI Statin Smoking Cessation Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews 10/2002
ACEI Class Review • Clinical Efficacy • Numerous agents • Varying degrees of literature support • FDA approved indications • Theoretical differences vs. hard outcomes vs. missing data • “Class Effect”? • Cost • Low-cost generics vs. brand • Pharmaceutical company detailing • Convenience • Once daily vs. BID dosing
ACEI Agent Market Share on Utilization (%) Market Share on Cost (%) Annual Cost ($) #1 Benazepril 36 47.5 119,000 #2 Lisinopril 40 41.0 103,000 #3 Enalapril 23 10.1 25,000 #4 Ramipril 0.1 0.5 1,500 #5 Captopril 1 0.3 700 TTL $249,200 Drug: Market Share and Annual Cost: Jan – Dec 01
Drug Use Evaluation (DUE) • Definition: Authorized, structured, ongoing review of practitioner prescribing, pharmacist dispensing and patient use of medications. • Purpose: To ensure drugs are used appropriately, safely, and effectively to • Improve patient care • Lower the overall cost of care • Foster more efficient use of health care resources • Process • Comprehensive review of medication use data • Identify patterns of prescribing
DUE Targets • Therapeutic appropriateness • Appropriate generic or FLA utilization • Inappropriate dose and/or duration • Over and underutilization • Compliance with polices/guidelines
DUE: Ramipril • Restrictions: • Limited Indications: HOPE Criteria • Cost: Trade name vs. generic alternatives • Appropriate Use • Chart reviews of users • Compare actual use to restriction criteria • Percent compliance rate • Assessment
# of Patients Receiving Ramipril # Patients that met HOPE Criteria # of Patients not meeting HOPE Criteria Total 40 33 6* HMC 34 28 5* UWMC 6 5 1 Ramipril DUE Results Overall, a 82.5% compliance rate for appropriate use. Of the 6 patients not meeting the HOPE criteria for ramipril use: -3 had only 1 identified risk factor (hypertension). -3 had documented EF < 40% secondary to MI or CHF along with numerous other risk factors and would have been eligible for treatment with 1st –line formulary agents.