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Drug Use Evaluation

Judith Coombes- Senior pharmacist PAH,conjoint lecturer UQ

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Objectives introduce quality cycle

DUE and evidence based medicine

DUE cycle

steps of DUE

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Quality CYCLE

ACT PLAN

DO

CHECK

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DUE CYCLE

ACTION COLLECTDATA

EVALUATEDATA

FEEDBACKEVALUATEDDATA

FEEDBACK

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CHECK =

AUDIT=

COLLECT DATA ANDEVALUATE

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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

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Judicious

Appropriate

Safeeffective

acceptable to patient(BARBER)

daily commitment of the pharmacist so what isdifferent

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QUM/Pharmaceutical care is patient orientated atthe 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

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Why have DUE? Clinical benefits

Evidence based medicine

Educational benefits

Economic benefits

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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

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Evidence Based medicine

Patient

Values

Clinical Expertise

Best research evidence

Decision

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Evidence Based Medicine

FIVE STEPS

Answerable question

best current evidence

validity, impact, applicability integrate with clinical expertise

evaluate performance

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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

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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

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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

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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)

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DUE STEPS(Australian Drug usage evaluation starter kit, The Society ofHospital 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

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DUE CYCLEACTION COLLECT

DATA

EVALUATEDATA

FEEDBACKEVALUATEDDATA

FEEDBACK

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STEPS in DUE (starter kit)

7-evaluate8-feedback evaluated data

9-Action

10-Assess results of repeat data collection11-Report, Publish, Present

12-Monitor and re-evaluate regularly

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Feedback reported on Areas wecould build upon:

PSI calculation and documentation,35% is a good start but can be

improved upon.

4/7 (57%) of class 1 and 2 patientsprescribed IV antibiotics

unnecessarily. .

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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 2005;183: 520-524

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INVOLVEMENT IN A NATIONALMULTICENTRE DUEAn evaluation by APOP participating Queensland hospitals

Donna R Taylor, Lisa K Pulver, Susan E Tett, Judith A Coombes.School of PharmacyUniversity 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 outcomesAim: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.

Conclusion:Project evaluation by the participants provided valuable projectde-briefing and useful management information for future national

multicentre projects.

The experience from all hospitals was very positive, and isencouraging for future participation in planned national multi-site

DUEs.

Acknowledgements:

Our grateful thanks for the development of the evaluation tooltothe 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 effortsand 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.

Background:14 hospitals participated in the Queensland arm of

the national NPS-funded Acute Postoperative Painproject (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 frameaboutright - 58%

MaterialsNPS Feedback useful/very useful - 85%

NPS Feedback used to

inform Academic Detailing - 100%customise Power Point presentation - 92%

Quality of material - good or excellent - 100%

Used manual - 86%Used website - 71%

The Queensland Team

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

PERCEIVED LEVEL of SUPPORT

0

10

20

30

40

50

60

70

80

90

100

Assistance

provided

Expected in

normal hours

Sufficient

hospital

support

Sufficient

information

provided

Support from

QLD

coordinator

%

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DUE CYCLE

ACTION COLLECTDATA

EVALUATEDATA

FEEDBACKEVALUATED

DATA

FEEDBACK

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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

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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

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Conclusion

DUE is for everyone DUE is not research in its purest form BUT

DUE is a way of changing practice