Pharmacy 483:

QI and DUE in QI and DUE in Pharmacy PracticePharmacy 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?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 Continuous Quality Improvement (CQI)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 Three Categories of Quality ImprovementImprovement

• 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 MethodologyQI MethodologyMany 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:AMI Treatment:3 QI Examples In Pharmacy3 QI Examples In Pharmacy

.

#1 Disease State Management

#2 Pharmacologic Class Review

#3 Drug Use Evaluation (DUE)

AMI Drug Treatment:AMI Drug Treatment:Assessing Quality IndicatorsAssessing 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:Quality of Care for AMI:Disease State Management Disease State Management

Focus on provision of key elements of carethat 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 AMIHMC Care Goals for AMIMeasure Goal Sampling Plan

AMI patient discharged on ASA

100% Chart Review

AMI patient discharged on ACEI

100% Chart Review

AMI patient discharged on Beta Blocker

100% Chart Review

AMI patient discharged on Statin (if LDL > 130)

100% Chart Review

Smokers with CV Condition will have

documented cessation advice/counseling

75% Chart and CIS documentation

review

HMC Rx Rates : HMC Rx Rates : Secondary Prevention in AMISecondary Prevention in AMI

Report from 10/2000, UHC Benchmarks

86 86

64

50

18

ASA Beta blocker ACEI Statin Smoking0

20

40

60

80

100

Per

cen

t o

f P

atie

nts

Cessation

AMI Treatment: AMI Treatment: Indicated Drugs Under Utilized?Indicated Drugs Under Utilized?

Problems Solutions• 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)

Pharmacist RolePharmacist 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 HMC Rates for Secondary Prevention in AMIPrevention in AMI

Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews 10/2002

94 9486 100

74

ASA Beta blocker ACEI Statin Smoking0

20

40

60

80

100

Per

cen

t o

f P

atie

nts

Cessation

ACEI Class Review 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: Drug: Market Share and Annual Cost: Jan – Dec 01Jan – Dec 01

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 Use Evaluation (DUE)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 TargetsDUE Targets

• Therapeutic appropriateness

• Appropriate generic or FLA utilization

• Inappropriate dose and/or duration

• Over and underutilization

• Compliance with polices/guidelines

DUE: RamiprilDUE: 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 40 33 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?QUESTIONS?