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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 COLLECT DATA ACTION 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 COLLECT DATA ACTION 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 community-acquired 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: Results: Key messages: 14 hospitals participated in the Queensland arm of the national NPS-funded Acute Postoperative Pain project (APOP). Response rate of 100%, Previous project participation informs accuracy of estimate of resource allocation Previous participation in a QI project* Aware of time commitment * (*Strong correlation) Team approach most effective, least draining Participants were invited to a state project wrap-up meeting to facilitate project de-briefing. 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 comprised equally of Pharmacy and Nursing Time frame ‘about right’ 100 Aim: - 36% 36% - 58% PERCEIVED LEVEL of SUPPORT 90 80 To evaluate the experience of participants in a national multi-centre DUE. 70 60 % 50 Conclusion: 40 Method: Participating hospitals were requested to complete a project evaluation questionnaire prior to the meeting, for presentation on the day. Project evaluation by the participants provided valuable project de-briefing and useful management information for future national multicentre projects. 30 20 10 0 Assistance provided Expected in normal hours Sufficient hospital support Sufficient information provided Support from QLD coordinator 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 positivePower impact at the hospital Point presentation • Quality wrt specific project aims of material - good or excellent (pain documentation, education, prescribing)Used manual • Used on the hospital dynamic website (collaboration/communication/teamwork) 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 85% - 100% 100% 92% ~50% 100% 86% ~50% 71% - 100% - 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 Women’s, Royal Darwin, Toowoomba and Wesley Private Hospitals. DUE CYCLE COLLECT DATA ACTION 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