1. QI and DUE in Pharmacy Practice Pharmacy 483: QI and DUE in Pharmacy Practice Steve Riddle, BS Pharm, BCPS QI and Medication Utilization Lead HMC Pharmacy February 24, 2004

2. 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?

3. Why do we need QI in pharmacy or in healthcare

4. 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

5. 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.

6. 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)

7. 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

8. AMI Treatment: 3 QI Examples In Pharmacy. #1 Disease State Management #2 Pharmacologic Class Review #3 Drug Use Evaluation (DUE)

9. 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?

10. 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)

11. HMC Care Goals for AMI MeasureGoalSampling 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

12. HMC Rx Rates : Secondary Prevention in AMI Report from 10/2000, UHC Benchmarks 86 64 50 18 ASABeta blockerACEIStatinSmoking 0 20 40 60 80 100 Percent of Patients Cessation

13. AMI Treatment: Indicated Drugs Under Utilized? AMI Treatment: Indicated Drugs Under Utilized? ProblemsSolutions 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)

14. Pharmacist 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

15. HMC Rates for Secondary Prevention in AMI Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews 10/2002 94 86 100 74 ASABeta blockerACEIStatinSmoking 0 20 40 60 80 100 Percent of Patients Cessation

16. 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

17. Drug: Market Share and Annual Cost: Jan – Dec 01 ACEI AgentMarket Share on Utilization (%) Market Share on Cost (%) Annual Cost ($) #1Benazepril3647.5119,000 #2Lisinopril4041.0103,000 #3Enalapril2310.125,000 #4Ramipril0.10.51,500 #5Captopril10.3700 TTL $249,200

18. 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

19. DUE Targets Therapeutic appropriateness Appropriate generic or FLA utilization Inappropriate dose and/or duration Over and underutilization Compliance with polices/guidelines

20. 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

21. Ramipril DUE Results # of Patients Receiving Ramipril # Patients that met HOPE Criteria # of Patients not meeting HOPE Criteria Total40336* HMC34285* UWMC651 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 1 st –line formulary agents.

23. QUESTIONS?