Proposal for development

of Quality Indicators based

on data about Prescribing

of Medication

HCQI Health promotion, prevention and primary care Sub Group

Agenda item 5, 9th May 2012

Flora M Haaijer-Ruskamp

Professor Drug utilization studies

University Medical Center Groningen/ University Groningen, Netherlands

Background

Prescribing important part of

– Health care

– Key therapeutic option in PHC

– Health care expenditure (19% OECD)

• Highlights health care quality breaches

• Functions as driver for quality improvement

Prescribing Quality Indicator (PQI)

• PQI’s are agreed by a range of stakeholders to be a valid method to measure or monitor prescribing quality

PQI’s are based on:

• Balance effectiveness/ safety

• Prescribing is in line with evidence based guidelines

Filter 1

• What are key areas of concern in sufficient countries

– = PQI are available

• Evidence of face and content validity

Key therapeutic areas for PHC

Antibiotics

The problem of resistance. Overuse has led to an increase of strains resistant to treatment, the emergence of infections that are increasingly difficult to treat, often need hospitalisations incurring much suffering and high costs.

Diabetes treatment

Proper treatment of diabetes patients is relevant for managing the diabetes, but is also essential for preventing complications, such as cardiovascular disease, renal failure. Proper treatment includes glycaemic control, as well as cardiovascular risk management.

Medication Safety [1]

Benzodiazepines and related medication, a large number of frequently occurring side effects, such as cognitive ability, aggressiveness, dependence or abuse, and falls (with associated fractures), of particular concern in the elderly.

Medication Safety [2]

The elderly are a high risk population, because of a greater risk of drug-disease and drug-drug interactions.

Selection process

• Validity

– In accordance with national evidence based guidelines and/or evidence

– Consensus among experts

• Reliability

– National infrastructure of reliable (prescribing) data bases for ambulatory care

• Comparability between countries

– International coding system

– Minimal confounding by case-mix

• Feasibility

– Comparable data available at national level in 8-10 countries

• Actionability:

– Amenable to change , alternative treatment is possible

– Usable in comparisons between regions

– Usable in quality improvement programs

– Usable for incentives policies

Filter 2

• Reliability

• Comparability

• Feasibility

Results selection based on

reliability, comparability and feasibility

criteria

PQI’s for HCQI in primary care should be

• based on available prescribing data in ambulatory care

– patient identifier (enabling measuring co- medication)

• Drug oriented indicators

• Disease oriented PQI limited to

– diseases measurable by using medication as proxy

Antibiotics for systemic use

PQI validity Rel. Comp

GL consensus

Overall volume + + + +

Overall volume of broad spectrum

+ + + +/-

Proportion broad spectrum na na + +/-

Proportion cephalosporines and quinolones

+ + + +

NB equally PHC

equally actionable

na=not assessed

Diabetes treatment PQI validity Rel. Comp

Undertreatment GL Cons. Pred.

cholesterol lowering + + + + +

antihypertensives + - - + -

First choice treatment

Choice of OAD +/- +/- na + +

Choice of RAS inhib (=ACEi/ ARB)

+ + na + +

na=not assessed

NB equally PHC

equally actionable

Medication Safety, Benzodiazepines for Elderly

PQI validity Rel. Comp

GL Cons

Proportion of users > 65 years who on average use at least half a DDD of benzodiazepines per day of all people > 65 years

+ + +

Proportion of users > 65 years who on average use at least 1.5 DDD of benzodiazepines per day of all people > 65 years

+ + +

the number of DDDs for benzodiazepines for elderly ( > 65 years) in the total population of > 65 years

+ + +

the number of DDDs for long-acting benzodiazepines patients > 65 years in the total population of > 65 years

+ + +

NB equally PHC equally actionable

Medication Safety elderly

PQI validity Rel. Comp PHC Actionable

Evidence based

Cons

Beers list + - + - - +

STOPP-list + + + +/- ? +

Drug Burden Index + na ? ? + +

Med Appropr Index ? na - - ? +

Polypharmacy + + + ? + ??

Avery et al + UK + ? ++ +

Proposal

• Feasibility study to ensure the comparability of the data needed for the proposed PQI’s

– Antibiotics (2 PQI’s)

– Diabetes treatment (2 PQI’s)

– Medication safety elderly: benzodiazepine use (2 PQI’s)

• Pilot study on the (shortened) list developed by Avery (2011) as a PQI for medication safety