Medication Use Evaluation Lobna AL Juffali,MSc Clinical Pharmacy Department

Acronyms Associated with the evaluation of medication use Drug use review (DUR) 1969 on prescription drugs Retrospective evaluation to monitor medication use patterns (trends) ,quantitative Antibiotic use Review (AUR): 1978 Retrospective evaluation of antibiotic use quantitative Limited to identifying pattern of use

Acronyms Associated with the evaluation of medication use Drug use Evaluation (DUE) : 1986 Multidisciplinary involvement Expansion of AUR to all drugs evaluation of prescribing and outcome only. Medication use evaluation (MUE): 1992 Expansion of DUE to include all medications Evaluation expanded to include all aspects of medication use: Prescribing, dispensing,administration,monitoring,and

Definition MUE is a performance improvement method that focuses on evaluating and improving medication –use processes with the goal of optimal patient outcomes Am J Hosp Pharm. 1996;53:1953-5

Objectives of MUE Promoting optimal medication therapy. Preventing medication-related problems. Evaluating the effectiveness of medication therapy. Improving patient safety. Establishing interdisciplinary consensus on medication-use processes. Stimulating improvements in medication-use processes. Stimulating standardization in medication-use processes.

Objectives of MUE Minimizing procedural variations that contribute to suboptimal outcomes of medication use. Identifying areas in which further information and education for health care professionals may be needed. Minimizing costs of medication therapy. Meeting or exceeding internal and external quality standards

MUE The MUE should be a systemic, multidisciplinary process focusing on continual improvement in the medication use process and patient outcomes Simply determines if the actual use of a medication is consistent with the standards established within the criteria

Types Of MUE Specific medication (e.g. alteplase) Class of medication (e.g., thrombolytics) Medications used in the management of a specific disease state or clinical setting (e.g. thrombolytics in acute myocardial infarction)

Types Of MUE Medications related to clinical event (e.g., drug therapy with in the first 24 hours for patients admitted with acute MI) Specific component of the medication use process (e,g time from admission to administration of thrombolytics Based on a specific outcome (vessel patency following thrombolytic administration)

Medication use process Prescribing dispensing administration monitoring, systems and management control Table 16-1

Ten-step process Assign responsibility for monitoring and evaluation Delineate scope of care and service provided by the organization Identify important aspects of care and service provided by the organization Identify indicators, datasources ,and collection methods to monitoring important aspects of care Establish means to trigger evaluation (e.g.,trends or patterns of use ,thresholds, etc.)

Ten-step process Collect and organize data Initiate evaluation of care Take actions to improve care and service Assess the effectiveness of actions and maintain the improvement Communicate results to relevant individuals and groups

Responsibility for the medication use evaluation function Defining which group will participate in They must have a clear understanding that the purpose is that of improving the quality of the medication use Each should actively participate

Topic Selection Based on the mission and scope of care Effect on performance and improved patient outcomes Selected high-volume, high-risk, or problem-prone processes medication processes Resources and organizational priorities Institutional priorities (initiation of new clinical programs or services)

Topic Selection They should reflect the over all scope of medication use throughout the organization Annual plan that will establish goals for new topics to be assessed and provide for follow-up on previous evaluations

Sources of Topic section Medication error reports ADRs Advances in patient care modalities that involve changes in optimal pharmacotherapy Disease-or diagnosis-based length of stay or cost outliers with in an organization Purchasing reports indicating a significant increase in the use of an agent Medications that are a key component of a process or procedure

Criteria Are statements of the activity to be measured Should be based on the best practice Appropriate for the target patient population Supported by current literature Multidisciplinary group develops the criteria Should be phrased yes/no or T/F Should avoid interpretation on the part of data collection Assess important aspects in the use of the medication evaluated Focus on aspects related to outcomes.

Types of criteria Explicit (objective) criteria are preferred in that they are clear cut, based on a specific measurable parameters and are better suited for automation e.g. serum creatinine evaluated every 3 days Implicit (subjective) criteria require that a judgment be made and require appropriate clinical expertise e.g. Renal function assessed routinely

Indicators It is a quantitative measure of an aspect of patient care that is used as screening tool to detect potential problems in quality. They are not direct measures of quality they simply work as a tool to identify potentially problematic aspects of care that require more detailed assessment in order to identify the cause. E.g. patient discharged on > x number of prescription medications

Type of indicators Rate based event (how often) Sentinel events (occur rarely but are significant impact) Assess structure (resources ,tools, and other established attributes of the setting in which care is provided) Assess Process (activities that take place in giving and receiving care) Assess outcome (the effects of care on the health status of the patient or population

Indicators Suggesting a Need for MUE Analysis Adverse medication events, including medication errors, preventable adverse drug reactions, and toxicity. Signs of treatment failures, such as unexpected readmissions and bacterial resistance to anti-infective therapy. Pharmacist interventions to improve medication therapy, categorized by medication and type of intervention. Nonformulary medications used or requested. Patient dissatisfaction or deterioration in quality of life.

Standards standards: define the performance expectations They are set at 0% (should never happen( 100% (should always happen) Thresholds specifying an acceptable level should be set higher then 0% and lower than 100%

Data collection Prior to initiation the multidisciplinary gp must approve Topic selection Criteria Patient selection process Sample size Sampling method Timeframe Data collection method Standards of performance

Data Collection Limiting the number of data collectors or automating data collection is valuable in maintaining consistency

Retrospective Data Collection Reviewing the patient’s medical record after Discharge e.g. AUR,DUR Data source: only medical records Allows data collection to be scheduled Totally depends on documentation Only to improve future patients

Concurrent Data collection After the first dose and the patient is still taking the medication Data source : medical records, staff, patent interviews There is an opportunity to improve patient care The need for data collection is constant and must occur within a specific timeframe, which is not always convenient Increase number of personal and increased inconsistency

Prospective Data Collection After prescribing the medication Before the patient take it Automated Not automated: require the personal to be available to collect and report Force immediate reactions with practitioners Greatest opportunity for intervention and education Increase the risk of negative reactions

Patient selection and Sample size Unbiased Consistent Representative of the care provided Sample size should be based on The size of patient population Frequently occurring events 5% Rare events minimum 30 cases

confidentiality It is a key component of all quality improvement initiatives The patients and the practitioners names should anonymous

Data analysis Reports should compare actual performance with expectations defined by the standards Performance not meeting standards they are considered opportunities for improvement Standards can be too rigorous? Specific corrective action should be recommended. A follow up should be started based on the needs and prevalence ,severity and frequency of the problem

The Report Should contain the rationale for the topic selection Team members involved in the evaluation Description of the patient population evaluated Any selection criteria used A copy of the criteria /indicators Discussion of the results Identification of likely causes for opportunities identified Recommendations for corrective action Follow –up evaluation

Interventions and correction actions

Follow up The same criteria, standards, and sample should be used for the follow up assessment as in the initial assessment

Pitfalls Lack of authority. Lack of organization. Poor communication. Poor documentation. Lack of involvement. Lack of follow-through Evaluation methodology that impedes patient care Lack of readily retrievable data and information man- agement. Existing data capabilities need to be as -