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

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

Quality CYCLE PLAN ACT CHECK Remember last year DO

DUE CYCLE COLLECT ACTION DATA FEEDBACK FEEDBACK EVALUATED DATA

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.).

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

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

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

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

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

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.

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

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

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

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)

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

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

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

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

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

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

Rancangan DUE berdasarkan waktu pengambilan data PROSPEKTIF KONKUREN RETROSPEKTIF

DUE CYCLE COLLECT ACTION DATA FEEDBACK FEEDBACK EVALUATED DATA

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

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

CONTOH DUE