Transcript Quality Improvement

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
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 Care Goals for AMI
Measure
Goal
Sampling Plan
AMI patient discharged
on ASA
AMI patient discharged
on ACEI
100%
Chart Review
100%
Chart Review
AMI patient discharged
on Beta Blocker
AMI patient discharged
on Statin (if LDL > 130)
100%
Chart Review
100%
Chart Review
Smokers with CV
Condition will have
documented cessation
advice/counseling
75%
Chart and CIS
documentation
review
HMC Rx Rates :
Secondary Prevention in AMI
Percent of Patients
100
86
86
80
64
60
50
40
18
20
0
ASA
Beta blocker ACEI
Report from 10/2000, UHC Benchmarks
Statin
Smoking
Cessation
AMI Treatment:
Indicated Drugs Under Utilized?
•
•
•
•
Problems
Provider lack of
awareness of benefits
Inconsistencies in
prescribing habits
Lack of use of current
prescribing aids
Complex processes
•
•
•
•
•
Solutions
 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)
Pharmacist Role
•
Collaborate in development of practice guidelines
–
–
•
Influence prescribing patterns
–
–
–
–
•
Committee involvement
Standing order and clinical pathway development
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
Percent of Patients
100
94
94
86
100
80
74
60
40
20
0
ASA
Beta blocker ACEI
Statin
Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews 10/2002
Smoking
Cessation
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
(%)
#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
Market Share
on Cost (%)
Annual Cost
($)
$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
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
Total
# of Patients
Receiving
Ramipril
40
# Patients that
met HOPE
Criteria
33
# of Patients not
meeting HOPE
Criteria
6*
HMC
34
28
5*
UWMC
6
5
1
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.
QUESTIONS?