Pharmaceutical and Therapeutics Committee

EVALUATING THE COSTS OF PHARMACEUTICALS

Medicine Use Evaluations

ObjectivesBy the end of this short course participants should be able to:•Understand the concept of medicine use evaluation (MUE)•Understand the process for implementing and performing an MUE•Discuss the use of an MUE program for improving prescribing and dispensing practice•Prepare criteria and threshold values for an MUE•Develop an MUE tool•Analysis of MUE results•Design an intervention strategy to improve medicine use.

Definition

Medicine Use EvaluationOngoing, systematic, criteria-based approach to assessing the use of medicines.

Interventions are necessary when inappropriate medicine use is identified.

Medicine Use Evaluation

An MUE is characterised by the following processes:

– Defining appropriate medicine use (by establishing criteria)

– Auditing criteria against what is being prescribed– Giving feedback to prescribers on all identified

deviations– Monitoring to see if criteria are followed and

prescribing practice is improved

Indicators suggesting a need for an MUE

• Over-use or under-use of medicine • Problems identified from indicators, audits or other

studies.• High incidence of adverse drug reactions associated

with a particular medicine• Signs of treatment failures• Excessive non-formulary medications used• Use of high-cost medicines where less expensive

alternatives exist• Excessive number of medicines within a therapeutic

category

Stepwise approach to an MUE1. Establish responsibility for managing MUE process2. Develop scope of activities3. Establish criteria and of the MUE (using evidence

based medicine)4. Establish thresholds5. Collect data and organize results6. Analyze data7. Develop recommendations and plan of action8. MUE follow-up

Step 1–Establish Responsibility

Subcommittee of the PTC (MDT)– Must include representation of practitioners

whose drug prescribing will be assessed

Step 2–Develop Scope of Activities

Identify medicine therapy problems to be addressed using • Top 40, • ABC/VEN analysis, • ADR reports, • AMR reports

Concentrate on medicines with highest potential for problems:

• High volume• Low therapeutic index • High ADR rate• Expensive medicines• Critically important medicines• Antimicrobials• Injectable medicines• Medicines used for off-label

indications• Medicines used for high-risk

patients

Step 3 – Establish CriteriaProcess Indicators•Indications—Correct use / justification for the medicine in question•Correct dose•Quantity dispensed•Monitoring is appropriate (e.g. lab tests)•Contraindications•Medicine interactions- significant medicine interactions, including medicine-medicine, medicine-food, and medicine-laboratory •Medicine administration (especially for injections)•Patient education (written and oral instructions)

Step 3 – Establish CriteriaOutcome Indicators•Patient outcomes (e.g., blood glucose, viral load)•Pharmacy administrative indicators (registers, data collection)•Pharmacy administration indicators •Accurate dispensing records •Appropriate use of generic medicines or therapeutic equivalents •Appropriate use of formulary medicines (code list / EDL) •Appropriate quantity dispensed

Step 4 Thresholds

• Thresholds define the expectations or goals for complying with the criteria (e.g. 90% of prescriptions for 3rd generation cephalosporins are for predefined serious infections).

• Define and establish thresholds or benchmarks below which corrective action will be taken.

• What is the correct dose of co-trimoxazole for an adult, nonpregnant woman with an uncomplicated urinary tract infection? • Would you be happy if 70% of patients were given the correct dose? • If not, what percentage would you be happy with?

Step 5 – Collect Data• Prospective evaluation

• done prior to medicine being dispensed to the patient• pharmacist can intervene prior to or at the time the

medicine is dispensed• Retrospective evaluation

• requires access to medical records• Sources of data

• patient charts, medical records, prescriptions, laboratory files

• manual systems versus computerized systems• needs minimum of 50-75 records

Step 6 – Analyze Data• Tabulate results for each indicator

• Analyze to see whether the threshold is met, e.g.: • In 70% of patients, predefined criteria for the prescribing of 3rd

generation cephalosporins were met — 20% short of threshold

• Determine why thresholds (benchmarks) are not met

• Analyze data quarterly or more frequently

Step 7 – Recommendations & Plan of Action• Recommendations to address

– Inappropriate use of medicines– Unacceptable patient outcomes

• Interventions to resolve medicine use problems• Education• Forms and procedures for prescribing• Prescribing restrictions• Essential Drug List (EDL) changes• Standard Treatment Guideline (STG) changes

Step 8 – MUE Follow-up

• Check to see that recommendations have been implemented

• Repeat MUE to see if problems with medicine therapy have been resolved

Reasons why MUEs Go Wrong• Lack of authority/responsibility

• Poor prioritization of medicine use problems

• Poor documentation of findings

• Inadequate follow-up

• Overly intrusive data collection and evaluation

• Failure to obtain “buy in” from medical staff

Summary• MUE is an assessment and feedback intervention

• Requires establishing criteria and thresholds

• Feedback to prescribers to improve prescribing (educational, managerial, regulatory interventions are usually required

• MUE is an important intervention which can be used to assist in ensuring that medicine therapy meets current standards and promote optimal medication therapy