1. Continuous Quality Improvement Drug Utilization Evaluation

2. Quality in Health Care What impacts the level of quality? –Differences in diseases –Differences in treatments –Differences in health providers –Differences in patients’ responses to therapy –Differences in patients’ expectations –Differences in patients’ perception of quality

3. Problems with Quality in Health Care Overuse (service provided but not needed) Under-use (service is needed but not available or provided) Misuse (correct services provided so poorly that benefit not seen)

4. Quality Assurance Older term: process to ensure that something is done or made well enough. Usually retrospective Focuses on a particular component of health care problem, not total health care of patient

5. Continuous Quality Improvement, Total Quality Management (CQI, TQM) Newer term: encompass all persons involved in the entire process of health care More statistical, data driven More prospective in nature

6. Who Sets Standards for TQM/CQI in U.S.? JCAHO accredits –hospitals –laboratories –home-care organizations –long-term care organizations –mental health organizations –integrated health systems

7. Who Sets Up and Oversees TQM/CQI? Hospital: P&T committee provides DUE/MUE’s LTCF: DRR mandated by HCFA Ambulatory Services: DUR mandated by OBRA’90, set up by state Medicaid programs. –Prospective: Patient counseling –Retrospective: Use Rx records, claim forms

8. Drug Usage Evaluation (DUE) Medication Usage Evaluation (MUE) Authorized, structured ongoing review of MD’s prescribing, RPh dispensing, and patient use of medication Prospective, Concurrent or retrospective

9. Prospective/Concurrent DUE Evaluation before med is dispensed. RPh can review med’s dosage, directions, patient information, drug interactions or duplicate therapy. Issues addressed: Drug disease contraindications, Therapeutic interchange, Generic substitution, Incorrect drug dosage, Inappropriate duration of drug treatment, Drug- allergy interaction, clinical abuse/misuse of drugs

10. Retrospective DUE Drug therapy is reviewed after med is dispensed. Simplest to perform Uses patient’s medical charts, computerized records, insurance claims, etc Similar steps to performing DRR, DUR Issues addressed: Appropriateness, over/under utilization, generic use, therapeutic duplication, drug- disease contraindication, incorrect drug dosage, inappropriate duration of treatment, clinical abuse/misuse

11. Steps in Conducting and DUE 1. Identify Criteria (optimal indicators)for evaluation. –Based on current standards of practice –supported by the literature –clear concise, complete –accurate –objective

12. Sample Indicators Used for appropriate indication? Correct dose/ route/ dosage time (time of day, w/ or w/o meals, dose spacing etc) Side effects/ adverse reactions/ contraindications and how were they resolved? Appropriate duration of treatment? allergy/drug-drug interactions/ drug-food interactions therapeutic duplication with other drugs (too many nausea or pain meds on board already-is this needed?) proper monitoring done? (lab tests/ pain scale issues etc) Did drug work? Within reasonable time frame? Optimal outcome?

13. Steps in Conducting a DUE 2. Measure actual use –data collection –Retrospective: use medical and Rx records or claim forms –Prospective: prior to or as patent is receiving drug/therapy.

14. Steps in Conducting a DUE 3. Compare between optimal and actual use –Determine causes for discrepancies. 4. Intervene –take corrective action if necessary look at prescribing patterns, medication misadventures, quality of drug therapy, economics

15. Intervention Steps Conduct educational programs for target groups Changing policies and procedures Correct or improve communication Provide more information Change indicators and or thresholds Restrict or revoke physician privileges Change the drugs available on formulary

16. 5. Evaluate the DUE Assess the effectiveness Evaluate outcomes Document reasons for positive and negative results Implement appropriate changes Continue observation

17. Example DUE: Ondansetron Criteria (indicators): Is drug used for proper indication? –Post-op nausea/vomiting –Pre/post chemotherapy Is drug prescribed in correct route/dose? –0.15 mg/kg IV 30 min pre-chemotherapy and at 4&8hrs –32 mg IV 30 min pre-chemo (one time use) –4mg IV q6h prn pre/post anesthesia or surgery

18. DUE Criteria (Indicators) cont... Did patient receive optimal outcome? –Was drug efficacious? –Was nausea/vomiting controlled w/in certain time frame or certain number of doses? Were there adverse effects? –HA, diarrhea, constipation, sedation, rash, lab abnormalities? Did they resolve spontaneously, or upon DC of drug?