Pharmacy 483:

1. Pharmacy 483: Quality Improvement inPharmacy Steve Riddle, BS Pharm, BCPS QI and Medication Utilization Lead HMC Pharmacy February 22, 2005

2. 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.

3. 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.

4. 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”

5. Acute Myocardial Infarction“Heart Attack” What should be done for this patient?

6. 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

7. 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)

8. 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” (other • institutions or natl. • performance)

9. HMC Baseline Rates for AMI Treatment 100 86 86 80 64 Percent of Patients 60 50 40 18 20 0 ASA Beta blocker ACEI Statin Smoking Cessation Report from 10/2000, UHC Benchmarks

10. 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!

11. AMI Treatment:QI Example Optimize Clinical Outcomes Efficient Use Of Resources Goals Disease-focused QI (example: treat AMI with ACE Inhibitors)

12. AMI Treatment: Why are indicated drugs under utilized? Problems Solutions  education/awareness of providers Provider Knowledge Inconsistent Prescribing • 1. Simplify processes • order sets, clinical pathways • 2. Designate specific responsibilities • 3. Add Clinical Care Coordinator or • pharmacist to clinical team Prescribing aids not used Complex processes

13. Did it work? Check that data!

14. HMC Rates for Secondary Prevention in AMI 100 94 94 100 86 80 74 60 Percent of Patients 40 20 0 ASA Beta blocker ACEI Statin Smoking Cessation Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews

15. QI Example #2: The DUE Optimize Clinical Outcomes Efficient Use Of Resources Goals Disease-focused QI (example: treat AMI with ACE Inhibitors) Drug-focused QI (example: use most cost- effective ACEI)

16. 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

17. 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

18. Angiotensin Converting Enzyme Inhibitor (ACEI) Class Cost -Generics vs brand -Reimbursement Captopril Enalapril Lisinopril Ramipril No major adverse effect differences Safety Effectiveness Unique indications

19. 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

20. 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.

21. 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

22. 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

23. QUESTIONS?