QI and DUE in Pharmacy Practice

Transcription

1 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? Why do we need QI in pharmacy or in healthcare

2 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)

3 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?

4 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 Care Goals for AMI Measure AMI patient discharged on ASA AMI patient discharged on ACEI AMI patient discharged on Beta Blocker AMI patient discharged on Statin (if LDL > 130) Smokers with CV Condition will have documented cessation advice/counseling Goal 100% 100% 100% 100% 75% Sampling Plan Chart Review Chart Review Chart Review Chart Review Chart and CIS documentation review Percent of Patients HMC Rx Rates : Secondary Prevention in AMI ASA Beta blocker ACEI Statin Smoking Cessation Report from 10/2000, UHC Benchmarks

5 AMI Treatment: Indicated Drugs Under Utilized? Problems Solutions Provider lack of education/awareness of providers awareness of benefits Simplify processes Inconsistencies in order sets, clinical pathways prescribing habits Designate specific Lack of use of current responsibilities prescribing aids Clinical Care Coordinator or Complex processes pharmacist on clinical team Use data (ie, daily admit printouts) 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 Percent of Patients HMC Rates for Secondary Prevention in AMI ASA Beta blocker ACEI Statin Smoking Cessation Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews 10/2002

6 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 Drug: Market Share and Annual Cost: Jan Dec 01 ACEI Agent Market Share on Utilization (%) Market Share on Cost (%) Annual Cost ($) #1 Benazepril ,000 #2 Lisinopril ,000 #3 Enalapril ,000 #4 Ramipril ,500 #5 Captopril TTL $249,200 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

7 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 Ramipril DUE Results # of Patients Receiving Ramipril # Patients that met HOPE Criteria # of Patients not meeting HOPE Criteria Total * HMC * UWMC 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 1 st line formulary agents.

8 QUESTIONS?