Pharmacy 483:

Steve Riddle, BS Pharm, BCPS

QI and Medication Utilization Lead

HMC Pharmacy

February 22, 2005

Quality Improvement inQuality Improvement inPharmacyPharmacy

Goals of Presentation

• Increase understanding and awareness of the nature quality improvement and the basic processes involved.

• Gain knowledge regarding the role of the pharmacists in quality improvement.

• Learn about Drug Use Evaluation (DUE) and the value it can provide.

How do we assess quality?

• Quality Assurance (QA): any systematic process of checking to see whether a product or service is meeting specified requirements

• Quality Improvement (QI)– Focus is on improvement of product or service or

process

• Continuous Quality Improvement (CQI)– not typically just one way to do something– because things are "done right the first time" does not

mean they cannot be done better.

Why do we need QI in pharmacy or in healthcare

• Provide the right care to each and every patient– The right test and assessments– Most effective treatments– The safest therapies (risk vs benefit)

• Responsible use of resources– Cost Effectiveness: “Best bang for the buck”

Acute Myocardial Infarction“Heart Attack”

What should be done for this

patient?

What are the goals in treating this AMI patient?

Procedures:PTCA

(Angioplasty)Labs and

Diagnostics: ECG, Echo, EF

Drug Therapy:ASA, ACEI,

Beta-blockers, Statins, Thrombolytics

Messages:Healthy Lifestyle, Diet,

Exercise, Stop Smoking

How are these goals determined?

• Clinical Guidelines per Professional Org– American Heart Association (AHA)– American College of Cardiology (ACC)– Local Institutional Groups (UW Med Cardiology)

• Oversight & Quality Organizations– Joint Commission for the Accreditation of

Healthcare Organizations (JCAHO)– Centers for Medicare & Medicaid Services (CMS)– Association for Healthcare Research & Quality

(AHRQ)

How do we evaluate performance?

DATA DATA DATA

…Establish “baseline” data information

• Collect data from treated patients

• Real-time or retrospective

Compare data to…• Institutional goals• “Benchmarks” (otherinstitutions or natl. performance)

HMC Baseline Rates for AMI Treatment

Report from 10/2000, UHC Benchmarks

86 86

64

50

18

ASA Beta blocker ACEI Statin Smoking0

20

40

60

80

100

Per

cen

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f P

atie

nts

Cessation

Identify areas in need of improvement…

Eliminate Quality Problems:•Improve use of most appropriate agent

•Remove unsafe agents

Reducing Costs… while maintaining or improving quality

•Generic product use•Therapeutic substitution

•Drug purchasing contracts

and put solutions into practice!

AMI Treatment:QI Example

OptimizeClinical Outcomes

Efficient UseOf Resources

Disease-focused QI(example: treat AMIwith ACE Inhibitors)

Goals

AMI Treatment: Why are indicated drugs under utilized?

Problems Solutions

Provider Knowledge

Inconsistent Prescribing

Prescribing aids not used

Complex processes

education/awareness of providers

1. Simplify processes

order sets, clinical pathways

2. Designate specific responsibilities

3. Add Clinical Care Coordinator or

pharmacist to clinical team

Did it work?

Check that data!

HMC Rates for Secondary Prevention in AMI

Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews

94 9486 100

74

ASA Beta blocker ACEI Statin Smoking0

20

40

60

80

100

Per

cen

t o

f P

atie

nts

Cessation

QI Example #2: The DUE

OptimizeClinical Outcomes

Efficient UseOf Resources

Disease-focused QI(example: treat AMIwith ACE Inhibitors)

Drug-focused QI(example: use most cost-

effective ACEI)

Goals

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

Examples of DUE Targets

• Therapeutic appropriateness

• Appropriate generic or ‘first-line agents’ utilization

• Inappropriate dose and/or duration

• Over and underutilization

• Compliance with polices/guidelines

Angiotensin Converting Enzyme Inhibitor (ACEI) Class

Cost

Safety

Effectiveness

-Generics vs brand-Reimbursement

No major adverse effect differences

Unique indications

CaptoprilEnalaprilLisinoprilRamipril

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

• 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 were eligible for treatment with 1st –line formulary agents.

# of patients receiving ramipril

# of patients meeting

HOPE criteria

# of patients not meeting

criteria

Total 40 33 6

HMC 34 28 5

UWMC 6 5 1

Pharmacist Role in QI

• 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– “Academic-detailing”

• Perform direct patient care roles– Anticoagulation service– Collaborative disease management protocols– Patient education programs

Specific Pharmacy Roles in QI(ie. Janet and myself)

• Develop, implement and oversee institutional and pharmacy department quality goals

• Work with administration, providers and pharmacy staff to assure goals are being met

• Provide data and feedback to stakeholders

QUESTIONS?QUESTIONS?