Continuous Quality Improvement

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Continuous Quality Improvement

• Drug Utilization Evaluation

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Quality in Health Care

• What impacts the level of quality?
• Differences in diseases
• Differences in treatments
• Differences in health providers
• Differences in patients responses to therapy
• Differences in patients expectations
• Differences in patients perception of quality

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Problems with Quality in Health Care

• Overuse (service provided but not needed)
• Under-use (service is needed but not available or
  provided)
• Misuse (correct services provided so poorly that
  benefit not seen)

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Quality Assurance

• Older term process to ensure that something is
  done or made well enough.
• Usually retrospective
• Focuses on a particular component of health care
  problem, not total health care of patient

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Continuous Quality Improvement, Total Quality
Management(CQI, TQM)

• Newer term encompass all persons involved in the
  entire process of health care
• More statistical, data driven
• More prospective in nature

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Who Sets Standards for TQM/CQI in U.S.?

• JCAHO accredits
• hospitals
• laboratories
• home-care organizations
• long-term care organizations
• mental health organizations
• integrated health systems

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Who Sets Up and Oversees TQM/CQI?

• Hospital PT committee provides DUE/MUEs
• LTCF DRR mandated by HCFA
• Ambulatory Services DUR mandated by OBRA90, set
  up by state Medicaid programs.
• Prospective Patient counseling
• Retrospective Use Rx records, claim forms

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Drug Usage Evaluation (DUE)Medication Usage
Evaluation (MUE)

• Authorized, structured ongoing review of MDs
  prescribing, RPh dispensing, and patient use of
  medication
• Prospective, Concurrent or retrospective

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Prospective/Concurrent DUE

• Evaluation before med is dispensed.
• RPh can review meds dosage, directions, patient
  information, drug interactions or duplicate
  therapy.
• Issues addressed Drug disease contraindications,
  Therapeutic interchange, Generic substitution,
  Incorrect drug dosage, Inappropriate duration of
  drug treatment, Drug-allergy interaction,
  clinical abuse/misuse of drugs

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Retrospective DUE

• Drug therapy is reviewed after med is dispensed.
• Simplest to perform
• Uses patients medical charts, computerized
  records, insurance claims, etc
• Similar steps to performing DRR, DUR
• Issues addressed Appropriateness, over/under
  utilization, generic use, therapeutic
  duplication, drug-disease contraindication,
  incorrect drug dosage, inappropriate duration of
  treatment, clinical abuse/misuse

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Steps in Conducting and DUE

• 1. Identify Criteria (optimal indicators)for
  evaluation.
• Based on current standards of practice
• supported by the literature
• clear concise, complete
• accurate
• objective

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Sample Indicators

• Used for appropriate indication?
• Correct dose/ route/ dosage time (time of day, w/
  or w/o meals, dose spacing etc)
• Side effects/ adverse reactions/
  contraindications and how were they resolved?
• Appropriate duration of treatment?
• allergy/drug-drug interactions/ drug-food
  interactions
• therapeutic duplication with other drugs (too
  many nausea or pain meds on board already-is this
  needed?)
• proper monitoring done? (lab tests/ pain scale
  issues etc)
• Did drug work? Within reasonable time frame?
  Optimal outcome?

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Steps in Conducting a DUE

• 2. Measure actual use
• data collection
• Retrospective use medical and Rx records or
  claim forms
• Prospective prior to or as patent is receiving
  drug/therapy.

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Steps in Conducting a DUE

• 3. Compare between optimal and actual use
• Determine causes for discrepancies.
• 4. Intervene
• take corrective action if necessary
• look at prescribing patterns, medication
  misadventures, quality of drug therapy, economics

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Intervention Steps

• Conduct educational programs for target groups
• Changing policies and procedures
• Correct or improve communication
• Provide more information
• Change indicators and or thresholds
• Restrict or revoke physician privileges
• Change the drugs available on formulary

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5. Evaluate the DUE

• Assess the effectiveness
• Evaluate outcomes
• Document reasons for positive and negative
  results
• Implement appropriate changes
• Continue observation

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Example DUE Ondansetron

• Criteria (indicators)
• Is drug used for proper indication?
• Post-op nausea/vomiting
• Pre/post chemotherapy
• Is drug prescribed in correct route/dose?
• 0.15 mg/kg IV 30 min pre-chemotherapy and at
  48hrs
• 32 mg IV 30 min pre-chemo (one time use)
• 4mg IV q6h prn pre/post anesthesia or surgery

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DUE Criteria (Indicators) cont...

• Did patient receive optimal outcome?
• Was drug efficacious?
• Was nausea/vomiting controlled w/in certain time
  frame or certain number of doses?
• Were there adverse effects?
• HA, diarrhea, constipation, sedation, rash, lab
  abnormalities?
• Did they resolve spontaneously, or upon DC of
  drug?