Medicine Use Evaluation s

1. Medicine Use Evaluations Pharmaceutical and Therapeutics Committee EVALUATING THE COSTS OF PHARMACEUTICALS

2. Objectives By the end of this short course participants should be able to: • Understand the concept of medicine use evaluation (MUE) • Understand the process for implementing and performing an MUE • Discuss the use of an MUE program for improving prescribing and dispensing practice • Prepare criteria and threshold values for an MUE • Develop an MUE tool • Analysis of MUE results • Design an intervention strategy to improve medicine use.

3. Definition Medicine Use Evaluation Ongoing, systematic, criteria-based approach to assessing the use of medicines. Interventions are necessary when inappropriate medicine use is identified.

4. Medicine Use Evaluation An MUE is characterised by the following processes: • Defining appropriate medicine use (by establishing criteria) • Auditing criteria against what is being prescribed • Giving feedback to prescribers on all identified deviations • Monitoring to see if criteria are followed and prescribing practice is improved

5. Indicators suggesting a need for an MUE • Over-use or under-use of medicine • Problems identified from indicators, audits or other studies. • High incidence of adverse drug reactions associated with a particular medicine • Signs of treatment failures • Excessive non-formulary medications used • Use of high-cost medicines where less expensive alternatives exist • Excessive number of medicines within a therapeutic category

6. Stepwise approach to an MUE • Establish responsibility for managing MUE process • Develop scope of activities • Establish criteria and of the MUE (using evidence based medicine) • Establish thresholds • Collect data and organize results • Analyze data • Develop recommendations and plan of action • MUE follow-up

7. Step 1–Establish Responsibility Subcommittee of the PTC (MDT) • Must include representation of practitioners whose drug prescribing will be assessed

8. Step 2–Develop Scope of Activities Identify medicine therapy problems to be addressed using • Top 40, • ABC/VEN analysis, • ADR reports, • AMR reports Concentrate on medicines with highest potential for problems: • High volume • Low therapeutic index • High ADR rate • Expensive medicines • Critically important medicines • Antimicrobials • Injectable medicines • Medicines used for off-label indications • Medicines used for high-risk patients

9. Step 3 – Establish Criteria Process Indicators • Indications—Correct use / justification for the medicine in question • Correct dose • Quantity dispensed • Monitoring is appropriate (e.g. lab tests) • Contraindications • Medicine interactions- significant medicine interactions, including medicine-medicine, medicine-food, and medicine-laboratory • Medicine administration (especially for injections) • Patient education (written and oral instructions)

10. Step 3 – Establish Criteria Outcome Indicators • Patient outcomes (e.g., blood glucose, viral load) • Pharmacy administrative indicators (registers, data collection) • Pharmacy administration indicators • Accurate dispensing records • Appropriate use of generic medicines or therapeutic equivalents • Appropriate use of formulary medicines (code list / EDL) • Appropriate quantity dispensed

11. Step 4 Thresholds • Thresholds define the expectations or goals for complying with the criteria (e.g. 90% of prescriptions for 3rd generation cephalosporins are for predefined serious infections). • Define and establish thresholds or benchmarks below which corrective action will be taken. • What is the correct dose of co-trimoxazole for an adult, nonpregnant woman with an uncomplicated urinary tract infection? • Would you be happy if 70% of patients were given the correct dose? • If not, what percentage would you be happy with?

12. Step 5 – Collect Data • Prospective evaluation • done prior to medicine being dispensed to the patient • pharmacist can intervene prior to or at the time the medicine is dispensed • Retrospective evaluation • requires access to medical records • Sources of data • patient charts, medical records, prescriptions, laboratory files • manual systems versus computerized systems • needs minimum of 50-75 records

13. Step 6 – Analyze Data • Tabulate results for each indicator • Analyze to see whether the threshold is met, e.g.: • In 70% of patients, predefined criteria for the prescribing of 3rd generation cephalosporins were met — 20% short of threshold • Determine why thresholds (benchmarks) are not met • Analyze data quarterly or more frequently

14. Step 7 – Recommendations & Plan of Action • Recommendations to address • Inappropriate use of medicines • Unacceptable patient outcomes • Interventions to resolve medicine use problems • Education • Forms and procedures for prescribing • Prescribing restrictions • Essential Drug List (EDL) changes • Standard Treatment Guideline (STG) changes

15. Step 8 – MUE Follow-up • Check to see that recommendations have been implemented • Repeat MUE to see if problems with medicine therapy have been resolved

16. Reasons why MUEs Go Wrong • Lack of authority/responsibility • Poor prioritization of medicine use problems • Poor documentation of findings • Inadequate follow-up • Overly intrusive data collection and evaluation • Failure to obtain “buy in” from medical staff

17. Summary • MUE is an assessment and feedback intervention • Requires establishing criteria and thresholds • Feedback to prescribers to improve prescribing (educational, managerial, regulatory interventions are usually required • MUE is an important intervention which can be used to assist in ensuring that medicine therapy meets current standards and promote optimal medication therapy