Drug Use Evaluation

Judith Coombes- Senior pharmacist PAH, conjoint lecturer UQ

Objectives
introduce quality cycle

DUE and evidence based medicine

DUE cycle steps of DUE

Quality CYCLE
ACT PLAN

CHECK

DO

DUE CYCLE
ACTION COLLECT DATA FEEDBACK
FEEDBACK EVALUATED DATA

EVALUATE DATA

CHECK = AUDIT= COLLECT DATA AND EVALUATE

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

Judicious Appropriate Safe effective acceptable to patient

(BARBER)

daily commitment of the pharmacist so what is

different

 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

Why have DUE?

Clinical benefits Evidence based medicine Educational benefits Economic benefits

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

Evidence Based medicine

Clinical Expertise

Patient Values Decision

Best research evidence

Evidence Based Medicine

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

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

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

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

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)

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

DUE CYCLE
ACTION COLLECT DATA FEEDBACK
FEEDBACK EVALUATED DATA

EVALUATE DATA

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

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. .

 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 communityacquired pneumonia in Australian emergency departments. Medical Journal of Australia 2005;183: 520-524

INVOLVEMENT IN A NATIONAL MULTICENTRE DUE

An evaluation by APOP participating Queensland hospitals
Donna R Taylor, Lisa K Pulver, Susan E Tett, Judith A Coombes. School of Pharmacy University of Queensland

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* Aware of time commitment * (*Strong correlation) 36% 36%

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

Time frame about right

58%

Aim:
To evaluate the experience of participants in a national multi-centre DUE.
%

100 90 80 70 60 50 40

PERCEIVED LEVEL of SUPPORT

Conclusion:
Project evaluation by the participants provided valuable project de-briefing and useful management information for future national multicentre projects.
Assistance provided Expected in normal hours Sufficient hospital support Sufficient information provided Support from QLD coordinator

Method:
Participating hospitals were requested to complete a project evaluation questionnaire prior to the meeting, for presentation on the day.

30 20 10 0

The experience from all hospitals was very positive, and is encouraging for future participation in planned national multi-site DUEs.

Acknowledgements:

Materials
NPS Feedback useful/very useful NPS Feedback used to inform Academic Detailing A customise Power Point presentation positive impact at the hospital Quality of material - good or excellent wrt specific project aims (pain documentation, education, prescribing)Used manual Used the hospital dynamic on website (collaboration/communication/teamwork) 85%

100% 100% 92% ~50% 100% 86% ~50% 71%

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.

A positive impact on the participant

The Queensland Team Increased confidence Increased project and people management skills Satisfaction in effecting behaviour change Satisfaction in collaboration

100%

DUE CYCLE
ACTION COLLECT DATA FEEDBACK
FEEDBACK EVALUATED DATA

EVALUATE DATA

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

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

Conclusion
DUE is for everyone

DUE is not research in its purest form BUT

DUE is a way of changing practice