Implementing Quality Use of Medicines – progress and challenges

1. Implementing Quality Use of Medicines – progress and challenges Gwen Higgins Deputy Manager Divisions’ Program Education and Quality Assurance Program

2. Overview: NPS and QUM • How Divisional and national programs are travelling • Work coming up: GP data demonstration project • Refunding submission

3. Established 1998 Public company with independent Board Membership based Contracted for a range of functions and savings on pharmaceutical expenditure Budgeted expenditure 2007-08 of about $30 million per annum Work in partnership – DGP partnerships are critical Almost a quarter of NPS budget goes directly to DGP Program delivery model has been very successful NPS model

4. Quality Use of Medicines • selecting management options wisely • choosing suitable medicines if a medicine is considered necessary • using medicines safely and effectively

5. Progress 1998 - 2008 • Ensure QUM is well understood by health professionals • Develop understanding of QUM by consumers • Create supportive environments • Demonstrate cost-effective improvement as a result of NPS work • Achieve recognition in QUM • Demonstrate business success (talent available, funders happy)

6. Choosing effective intervention/ improvement methods for QUM • Academic detailing – individual adoption, personalises to individual’s risk aversion, attitudes, values, knowledge • Audit and feedback – measurable and valid, non-controversial, patient specific • Peer group methods – social persuasion, problem based ‘learning’ Other • Opinion leaders – social persuasion • Patient mediated • Specialised clinical service delivery e.g. HMR, heart failure clinics

7. Increasing Percentage of agreed GPs (n= 14,165) who have participated in divisional NPS activities

8. Division performance – core deliverables 2006-07

9. Victoria and Tasmania performance - core deliverables 2007-08

10. Number of divisions delivering direct to pharmacists and nurses

11. NPS Facilitators: years of service

12. Other activities in past 12-18 months

13. Community • Generic medicines • Self management of arthritis • Seniors and multicultural communities • Working with Diabetes Australia • Get to know your medicines campaign • Working with Aboriginal health workers • Learning and teaching • Prescribing curriculum incl dental modules • Multidisciplinary learning modules • Nurse practitioner project • OTD project • GP registrar project

15. Hypertension – QUM issues • Known benefits of ‘tight control’ • Initiation of treatment, non-drug interventions • Frequency of monitoring • Appropriate drug selection • Use of low dose thiazide, use of ACEI or AT2RA in diabetes with microalbuminuria/proteinuria, use of beta blocker post-MI • Need for multiple agents for most patients, all with adverse effects • Asymptomatic disease, patient agreement/concordance essential

16. Is quality prescribing of antihypertensives achieved? NPS clinical audits – data from participating GPs See also O'Riordan S, Mackson J, Weekes L. Self-reported prescribing for hypertension in general practice. J Clin Pharm Ther. 2008;33(5):483-8.

17. Chronic heart failure • Known benefits from therapeutic regimens • Difficult drugs to initiate and titrate-up safely • Avoidance of exacerbating drugs • Patients with multiple co-morbidities, application of evidence • Increasing use of ACE inhibitors (or AT2RAs), up-titration still needed • Under-use beta-blockers but rapidly increasing

18. Prescribing Data in General Practice Demonstration Project - background • Since 1998 recognised data gap: timely, meaningful feedback • Medicare data is a poor substitute for locally relevant data • Individual DGP piloting projects that involved data extraction • Enhanced Divisional QUM project • NPS prescribing indicators project • Primary care collaboratives • NPS proposal to improve use of prescribing data using surplus funds

19. Prescribing Data in General Practice Demonstration Project - Progress Project scoped Quality improvement intervention designed Partnership Consultation with AGPN Consultation with software vendors Steering group Prescribing indicators QPI incentive

20. Prescribing Data in General Practice Demonstration Project - Objectives • To develop a sustainable model of quality improvement in general practice that GPs can apply to their prescribing practice • To develop an effective easy-to-use data extraction tool that will assist GPs to compare their prescribing practice with NPS indicators of quality prescribing • To demonstrate improvements in prescribing consistent with prescribing indicators • To demonstrate improvements in markers of positive health outcomes • To measure the impact of the quality improvement intervention on the PBS

21. Prescribing Data in General Practice Demonstration Project Several cycles of data extraction and facilitated practice based data reviews (audit and feedback) Data extraction software (Canning tool) Prescribing indicators - Management of hypertension - Management of chronic heart failure

22. Prescribing Data in General Practice Demonstration Project • Several cycles of data extraction and facilitated practice based data reviews (audit and feedback) • Data extraction software (Canning tool) • Prescribing indicators - Management of hypertension - Management of chronic heart failure

23. Prescribing Data in General Practice Demonstration Project - Antihypertensive Agent Indicators • Patients using at least one antihypertensive drug whose latest BP is ≥ 140/90mmHg • Patients using at least one prohypertensive drug whose latest BP is ≥ 140/90mmHg • Patients with coronary heart disease/diabetes/renal insufficiency/stroke/TIA /proteinuria 0.25 – 1.0 g/day whose latest BP is ≥ 130/80mmHg • Patients with diabetes and microalbuminuria/ macroalbuminuria/proteinuria not using an ACEI or angiotenin II-receptor antagonist • Patients using an ACEI or angiotenin II-receptor antagonist who are also using systemic NSAID and a diuretic

24. Prescribing Data in General Practice Demonstration Project – Other Indicators Chronic Heart Failure • CHF patients not using an ACEI or angiotenin II-receptor antagonist • CHF patients using an ACEI below the recommended dose • CHF patients using an ACEI or angiotenin II-receptor antagonist and not using a heart-failure specific beta blocker • CHF patients using a drug that may exacerbate the disease General QUM • Prescriptions printed within the last 3 months with no ‘reason for prescribing’ recorded

25. Prescribing Data in General Practice Demonstration Project • Expressions of interest anticipated early 2009 • Divisions with capacity to support data activities • 180 practices to participate • Funding for project facilitator (change agent) • Training, networking and materials for project facilitator • Funding similar to NPS Agreement

26. Refunding 2009-13 • Priorities focussed on health and economic outcomes • Renegotiating contracts 2009-13

27. 10 year goals (health and economic outcomes) • Ensure QUM is well understood and used by the community and health professionals • Create supportive environments by embedding QUM principles in health systems and practices • Demonstrate cost-effective improvement in health outcomesas a result of NPS work • Achieve recognition as a centre of excellence in QUM and related technologies • Demonstrate business success (talent available, funders happy, secure income, agile business processes)

28. Challenges for the future • E health solutions delivering on continuity of care in medicines management • Evidence gaps in older and very old people • QUM with focus on prevention • Harder drug use issues yet to be tackled • Complementary medicines increasingly used • End of life care

29. In summary • Established services with strong links to DGP • Opportunities for new work • Ensuring we continue to build capacity and link QUM more effectively into other primary care and DGP work

30. Questions and discussion