1. Drug Used Evaluation TUNGGUL ADI P. CLINICAL PHARMACY LABORATORY,
DEPARTMENT OF PHARMACY
Faculty of Medicine and Health Sciences
Jenderal Soedirman University
Purwokerto

3. Objectives introduce quality cycle DUE and evidence based medicine
DUE cycle
steps of DUE
Using an example

4. Quality CYCLE
PLAN
ACT
CHECK
Remember last year DO

5. DUE CYCLE COLLECT ACTION DATA FEEDBACK FEEDBACK EVALUATED DATA

6. Definisi DUE dan MUE (WHO)
Drug use evaluation (DUE) is a system of ongoing, systematic, criteria-based evaluation of drug use that will help ensure that medicines are used appropriately (at the individual patient level). If therapy is deemed to be inappropriate, interventions with providers or patients will be necessary to optimize drug therapy. A DUE is drug- or disease-specific and can be structured so that it will assess the actual process of prescribing, dispensing or administering a drug (indications, dose, drug interactions, etc.). DUE is the same as drug utilization review (DUR) and terms are used synonymously.
Medication use evaluation (MUE) is similar to DUE but emphasizes improving patient outcomes and individual quality of life; it is, therefore, highly dependent on a multidisciplinary approach involving all professionals dealing with drug therapy. An MUE will assess clinical outcomes (cured infections, decreased lipid levels, etc.).

7. What is a DUE programme?
really a quality assurance programme specific to medications
Promote Pharmaceutical Care (via a partnership)
Judicious
appropriate
safe
effective -improve quality of life

8. Judicious Appropriate Safe effective acceptable to patient
daily commitment of the pharmacist so what is different

9. Pharmaceutical care is patient orientated at the individual level
‘achieving definite outcomes that
improve patients quality of life’ Hepler, Strand 1990
DUE is Drug/Disease  at the hospital (or even country) level

10. Why have DUE?
Clinical benefits: evaluate outcome and reduce adverse effect
Evidence based medicine
Educational benefits
Economic benefits

11. Evidence Based medicine
Clinical Expertise
Patient Values
Decision
Evidence-based medicine(EBM) is the integration of best research evidence with clinical expertise and patient values (Sackett et al 1999)
audit actual medication usage in light of evidence
4th years – clopidogrel audit
Best research evidence

12. Evidence Based Medicine
FIVE STEPS
Answerable question
best current evidence
validity, impact, applicability
integrate with clinical expertise
evaluate performance
DUE is where we can evaluate performance and then do something to improve performance if necessary.

13. Economic benefits
potential to identify efficiencies (often duration reduced)
potential to justify expenditure

14. Goals of the Program
Improve the quality of patient care by improving the clinical use of medications and minimizing adverse drug reactions
Decrease hospital costs by eliminating the inappropriate use of drugs or by offering acceptable low cost substitutions
Decrease liability associated with the inappropriate use of high risk drugs

15. Who is involved in DUE? DUE pharmacist/Post Grad/Projec
Clinical Pharmacists
The whole pharmacy department.
Prescribers/consultants
Nurses
Patients
Drug and Therapeutics committee

16. Examples
Community Acquired Pneumonia in Australian Hospitals (CAPTION)
Acute Post operative pain (APOP)
Deep Vein Thrombosis prophylaxis in hospital
Discharge Medication for Acute Coronary Syndrome (DMACS)

17. UNSUR DASAR EPO Identifikasi masalah penting Menetapkan prioritas
Kriteria/standar penggunaan obat
Mengkaji masalah yang ada dengan kriteria yang sesuai
Solusi masalah
Memantau solusi dan keefektifannya
Dokumentasi

18. Penentuan Prioritas Berdasarkan Penyakit:
Kelompok pasien yang masuk rumah sakit dengan penyakit komplikasi
Kelompok pasien dengan kerusakan organ vital (jantung, ginjal, dan hati) yang signifikan
Pasien lanjut usia, pediatrik, ibu hamil, dan menyusui

19. Penentuan Prioritas Berdasarkan Terapi Obat:
Kelompok pasien yang menerima obat dengan risiko tinggi reaksi toksisitas (antikoagulan, antibiotika, antineoplastik)
Pasien yang diobati dengan polifarmasi

20. Penentuan Prioritas PRINSIP: Masalah harus secara klinik signifikan:
Frekuensi penggunaan obat
Frekuensi dan keparahan reaksi merugikan
2. Dapat diperbaiki

21. DUE STEPS (Australian Drug usage evaluation starter kit, The Society of Hospital Pharmacists, Melbourne 1998)
1-make a start (who will support you)
2-identify drugs/areas of practice for review
(examples; Vancomycin, Community acquired pneumonia)
3-critical literature evaluation (EBM)
4-define criteria
5-Data collection form
6-collect data
1 make a start, this what you do before you have en committed to the drug/disease you are interested in. Find out who will support you .
Step 2
Identify drug or disease state for review
I will use a few examples here to go through the steps of DUE
One is Community Acquired Pneumonia
Vancomycin and intravenous antibiotic- ever heard of VRE
One is DVT prophylaxis- remember the economy class syndrome
3/ Cochrane Library, Clinical Evidence. This is a time when you need the full paper, methods may give you ideas for your audit methodology.
4/ Define Criteria-indication
Process
Outcomes
5/ Data collection form-
Study design prospective or retrospective,
design of a form and Pilot

22. STEPS in DUE (starter kit)
7-evaluate 8-feedback evaluated data 9-Action 10-Assess results of repeat data collection 11-Report, Publish, Present 12-Monitor and re-evaluate regularly
7. To evaluate the data you need to summarise your data to produce results which you can use:
1/ to communicate to others- you can’t present people with a pile of data collection forms
2/ to compare with your criteria/standards and published reports.
8. Feedback
A paper
a presentation –staff meeting, educational meeting
individual feedback –academic detailing
Here Vancomycin and DVT were popular and presentations as in the media so people interested and wanted to contribute to actions.
9. Action
no change
no change but monitor
action-Formulary restriction, guidelines, drug bulletin, verbal presentation, one on one- academic detailing, posters
10. Back to the cycle and collect data
PUBLISH

23. Rancangan DUE berdasarkan waktu pengambilan data
PROSPEKTIF
KONKUREN
RETROSPEKTIF

25. DUE CYCLE COLLECT ACTION DATA FEEDBACK FEEDBACK EVALUATED DATA

26. DUE Studies NSAIDs in the community (GP and Pharmacist)
Antibiotics in Community acquired pneumonia
Vancomycin
Antiemetics in Chemotherapy
DVT Prophylaxis
UTI management
Secondary prevention post MI
Aspirin use as secondary prevention of MI in the community
Antibiotic prophylaxis in surgery
Benzodiazepine use
National Prescribing Service DUEs/Audits

27. Limitations methodology Ideal outcome impractical to measure
levels of evidence, Cochrane Collaboration
Systematic review- level 1
RCT- level 2
cohort level 3 or 4
Ideal outcome impractical to measure
resources (time and personnel)-now breakthrough method sometimes used
tip of the iceberg
incomplete/ not completable

28. CONTOH DUE