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

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 Report from 10/2000, UHC Benchmarks 86 64 50 18 ASABeta blockerACEIStatinSmoking 0 20 40 60 80 100 Percent of Patients Cessation

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 Disease-focused QI (example: treat AMI with ACE Inhibitors) Goals

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

13. Did it work? Check that data!

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

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

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 Safety Effectiveness -Generics vs brand -Reimbursement No major adverse effect differences Unique indications Captopril Enalapril Lisinopril Ramipril

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 1 st –line formulary agents. # of patients receiving ramipril # of patients meeting HOPE criteria # of patients not meeting criteria Total40336 HMC34285 UWMC651

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?