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Pharmacy 483:. Quality Improvement in Pharmacy. Steve Riddle, BS Pharm, BCPS QI and Medication Utilization Lead HMC Pharmacy February 22, 2005. Goals of Presentation. Increase understanding and awareness of the nature quality improvement and the basic processes involved. - PowerPoint PPT Presentation
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Pharmacy 483:
Steve Riddle, BS Pharm, BCPS
QI and Medication Utilization Lead
HMC Pharmacy
February 22, 2005
Quality Improvement inQuality Improvement inPharmacyPharmacy
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.
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.
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”
Acute Myocardial Infarction“Heart Attack”
What should be done for this
patient?
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
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)
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” (otherinstitutions or natl. performance)
HMC Baseline Rates for AMI Treatment
Report from 10/2000, UHC Benchmarks
86 86
64
50
18
ASA Beta blocker ACEI Statin Smoking0
20
40
60
80
100
Per
cen
t o
f P
atie
nts
Cessation
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!
AMI Treatment:QI Example
OptimizeClinical Outcomes
Efficient UseOf Resources
Disease-focused QI(example: treat AMIwith ACE Inhibitors)
Goals
AMI Treatment: Why are indicated drugs under utilized?
Problems Solutions
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
Did it work?
Check that data!
HMC Rates for Secondary Prevention in AMI
Data from HMC Dsch Diagnosis Coding for AMI and CIS reviews
94 9486 100
74
ASA Beta blocker ACEI Statin Smoking0
20
40
60
80
100
Per
cen
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f P
atie
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Cessation
QI Example #2: The DUE
OptimizeClinical Outcomes
Efficient UseOf Resources
Disease-focused QI(example: treat AMIwith ACE Inhibitors)
Drug-focused QI(example: use most cost-
effective ACEI)
Goals
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
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
Angiotensin Converting Enzyme Inhibitor (ACEI) Class
Cost
Safety
Effectiveness
-Generics vs brand-Reimbursement
No major adverse effect differences
Unique indications
CaptoprilEnalaprilLisinoprilRamipril
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
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.
# of patients receiving ramipril
# of patients meeting
HOPE criteria
# of patients not meeting
criteria
Total 40 33 6
HMC 34 28 5
UWMC 6 5 1
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
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
QUESTIONS?QUESTIONS?