Drug Use Evaluation

1
Drug Use Evaluation
Judith Coombes- Senior pharmacist PAH, conjoint
lecturer UQ
2
Objectives

• introduce quality cycle
• DUE and evidence based medicine
• DUE cycle
• steps of DUE

3
Quality CYCLE
PLAN
ACT
CHECK
DO
4
DUE CYCLE
COLLECT DATA
ACTION
FEEDBACK
FEEDBACK EVALUATED DATA
EVALUATE DATA
5

• CHECK
• AUDIT
• COLLECT DATA AND EVALUATE

6
What is a DUE programme?

• really a quality assurance programme specific to
  medications
• Promote QUM (via a partnership)
• Judicious
• appropriate
• safe
• effective -improve quality of life

7
JudiciousAppropriateSafe effectiveacceptable
to patient(BARBER)

• daily commitment of the pharmacist so what is
  different

8

• QUM/Pharmaceutical care is patient orientated at
  the individual level
• achieving definite outcomes that
• improve patients quality of life Hepler, Strand
  1990
• DUE is Drug/Disease orientated at the hospital
  (or even country) wide level

9
Why have DUE?

• Clinical benefits
• Evidence based medicine
• Educational benefits
• Economic benefits

10
Clinical benefits

• Evaluate outcome
• nausea and vomiting-nausea diary
• pain control-pain scales
• incidence of DVT
• reduce adverse effects
• Thrombocytopenia with heparin
• Reduce antibiotic resistance
• Reduce risks of infection if IV route not needed

11
Evidence Based medicine
Patient Values
Clinical Expertise
Decision
Best research evidence
12
(No Transcript)
13
(No Transcript)
14
Evidence Based Medicine

• FIVE STEPS
• Answerable question
• best current evidence
• validity, impact, applicability
• integrate with clinical expertise
• evaluate performance

15
Educational Benefits

• Pharmacists collecting data improve clinical
  skills
• Calculate PSI
• Use pain scores
• Junior Doctors
• learn during data collection (dose, duration)
• Consultants, Prescribers, Pharmacists, nurses,
  others involved
• feedback-grand rounds, bulletins, prescribing
  guidelines, academic detailing

16
Economic benefits

• potential to identify efficiencies (often
  duration reduced)
• potential to justify expenditure
• step back to hospital costs rather than drug
  costs (EG Low Molecular Weight Heparin)
• identify outcome benefits

17
Who is involved in DUE?

• DUE pharmacist/Post Grad/Project
• QUM projects in 4th year
• Clinical Pharmacists
• The whole pharmacy department.
• Prescribers/consultants
• Nurses
• Patients
• Drug and Therapeutics committee
• National Prescribing Service in Australia

18
Examples

• Community Acquired Pneumonia in Australian
  Hospitals (CAPTION)
• Acute Post operative pain (APOP)
• Deep Vein Thrombosis prophylaxis in hospital
• Discharge Medication for Acute Coronary Syndrome
  (DMACS)

19
DUE STEPS(Australian Drug usage evaluation
starter kit, The Society of Hospital Pharmacists,
Melbourne 1998)

• 1-make a start (who will support you)
• 2-identify drugs/areas of practice for review
• (examples Vancomycin, Community acquired
  pneumonia, Pain, DVT prophylaxis)
• 3-critical literature evaluation (EBM)
• 4-define criteria
• 5-Data collection form
• 6-collect data

20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
DUE CYCLE
COLLECT DATA
ACTION
FEEDBACK
FEEDBACK EVALUATED DATA
EVALUATE DATA
24
STEPS in DUE (starter kit)

• 7-evaluate
• 8-feedback evaluated data
• 9-Action
• 10-Assess results of repeat data collection
• 11-Report, Publish, Present
• 12-Monitor and re-evaluate regularly

25
Community Acquired Pneumonia Feedback reported on
Areas we could build upon

• PSI calculation and documentation, 35 is a good
  start but can be improved upon.
• 4/7 (57) of class 1 and 2 patients prescribed IV
  antibiotics unnecessarily. .

26

• Baseline
• Detailing and feedback
• Re-audit
• Detailing and feedback
• Re-audit
• Conference presentation
• MJA article
• Maxwell DJ, McIntosh KA, Pulver LK, Easton KL for
  the CAPTION Study Group. Empiric management of
  community-acquired pneumonia in Australian
  emergency departments. Medical Journal of
  Australia 2005183 520-524

27
INVOLVEMENT IN A NATIONAL MULTICENTRE DUE An
evaluation by APOP participating Queensland
hospitalsDonna R Taylor, Lisa K Pulver, Susan E
Tett, Judith A Coombes.School of Pharmacy
University of Queensland

• Key messages
• Previous project participation informs accuracy
  of estimate of resource allocation
• Team approach most effective, least draining
• Hard copy project manual used more than website
• Support and accessibility of state project
  officer highly valued
• NPS material highly regarded
• Positive hospital impact at all sites
• 100 of participants reported positive personal
  outcomes

Background 14 hospitals participated in the
Queensland arm of the national NPS-funded Acute
Postoperative Pain project (APOP). Participants
were invited to a state project wrap-up meeting
to facilitate project de-briefing.
Results Response rate of 100,
comprised equally of Pharmacy and
Nursing Previous participation in a QI
project - 36 Aware of time commitment
- 36 (Strong correlation) Time
frame about right - 58 Material
s NPS Feedback useful/very useful - 85 NPS
Feedback used to inform Academic Detailing -
100 customise Power Point presentation - 92 Qu
ality of material - good or excellent -
100 Used manual - 86 Used website - 71
Conclusion Project evaluation by the
participants provided valuable project
de-briefing and useful management information for
future national multicentre projects. The
experience from all hospitals was very positive,
and is encouraging for future participation in
planned national multi-site DUEs.
Acknowledgements Our grateful thanks for the
development of the evaluation tool to the
state-based DUE group in Victoria, and for the
support provided by NPS and all state-based DUE
groups - NSW, Tasmania, South Australia and
Victoria. And to the participating Qld hospitals
for their significant efforts and achievements in
improving the quality of patient care
Greenslopes Private, Ipswich, Logan, Nambour,
Mater Mothers Private, Mater Public, Princess
Alexandra, Redcliffe, Caboolture, Redland, Royal
Brisbane and Womens, Royal Darwin, Toowoomba and
Wesley Private Hospitals.
PERCEIVED LEVEL of SUPPORT
Aim To evaluate the experience of
participants in a national multi-centre DUE.
Method Participating hospitals were requested
to complete a project evaluation questionnaire
prior to the meeting, for presentation on the
day.

• A positive impact at the hospital - 100
• wrt specific project aims - 50
• (pain documentation, education, prescribing)
• on the hospital dynamic - 50
• (collaboration/communication/teamwork)

• A positive impact on the participant - 100
• Increased confidence
• Increased project and people management
  skills
• Satisfaction in effecting behaviour change
• Satisfaction in collaboration

The Queensland Team
28
DUE CYCLE
COLLECT DATA
ACTION
FEEDBACK
FEEDBACK EVALUATED DATA
EVALUATE DATA
29
DUE Studies

• NSAIDs in the community (GP and Pharmacist)
• Antibiotics in Community acquired pneumonia
• Vancomycin
• Antiemetics in Chemotherapy
• DVT Prophylaxis
• UTI management
• Secondary prevention post MI
• Aspirin use as secondary prevention of MI in the
  community
• Antibiotic prophylaxis in surgery
• Benzodiazepine use
• National Prescribing Service DUEs/Audits

30
(No Transcript)
31
Limitations

• methodology
• levels of evidence, Cochrane Collaboration
• Systematic review- level 1
• RCT- level 2
• cohort level 3 or 4
• Ideal outcome impractical to measure
• resources (time and personnel)-now breakthrough
  method sometimes used
• tip of the iceberg
• incomplete/ not completable

32
Conclusion

• DUE is for everyone
• DUE is not research in its purest form BUT
• DUE is a way of changing practice