promoting high quality, cost effective drug therapy throughout the military health system the basics...

Promoting high quality, cost effective drug therapy throughout the Military Health System

The Basics for a Successful MTF P&T Meeting

Prepared by the DoD Pharmacoeconomic Center

DoD Pharmacoeconomic Centerwww.pec.ha.osd.mil

Introduction

• LCDR Joseph B. Lawrence– PEC Navy Pharmacist Consultant

• Purpose of discussion– Basic tools and strategies for P&T

– Mock agenda for a MTF P&T


Topics of Discussion

• Purpose of P&T

• Organization and operation

• Functions and scope

• Assembling a quality meeting agenda

• Information resources for MTF specific data and research

• Medication use evaluation

• Drug class review.

• Reports

• JCAHO and other surveys


Purposes

• Policy development– Evaluation, selection and therapeutic use of drugs

and related devices

• Education– Programs for drug related matter for medical team

• Goal– ensure medications are used safely and

appropriately


Organization and Operation

• Composition: physicians, pharmacists, nurses, administrators, QA coordinators, others

• Physician chairperson

• Pharmacist recorder

• Meet regularly

• Invite ad hoc members and specialist as needed

• Sufficient time to review meeting materials

• Recommendation presented to medical staff

• Liaison with other organization committees concerned with drug use

• Actions routinely communicated

• Conflict of interest policy

• Attentive to ASHP, AHA, JCAHO, DOD, ect…


P&T Committee

• Organization– Chairperson

• Respected member of medical staff

• Familiar with and advocate for progressive pharmacy

• Effective ally for pharmacy with medical staff and hospital administration

– Secretary• Director of Pharmacy

• Sets agenda with chairperson


Functions and Scope

• Evaluative, education and advisory capacity to the med staff

• Develop a formulary of drugs for the organization

• Programs/procedures to help ensure the safe and effective drug therapy

• Programs/procedures to ensure cost-effective drug therapy

• Educational programs for medical team

• Participate in QA activities regarding medication

• Monitor/evaluate ADR

• DUE

• Advise pharmacy in effective drug distribution and control

• Disseminate information of actions to health-care staff


P&T Agenda

• Delivered via member preference (email, hard copy, etc)• Delivered with adequate time to review before meeting (1 week)• Informative enclosures

– Eg: drug monographs, adverse drug reaction reports, and policy changes

• Date/time/location of the meeting• Review of old business

– Medical staff notification– Minute routing comments– Pharmacy budget– Standing issues

• New business– Requests for change in formulary– Drug/product complaint– Drug recalls– Narcotic overlap– ADR– Planning for next meeting


P&T Committee

• Organization– Follow-up

• Actions should be conveyed to all health-care professionals

• Recommendations are to be passed on to the appropriate committee


Formulary Management

• Formulary

– Definition: a continually revised compilation of pharmaceuticals that reflects the clinical judgment of the medical staff



• Formulary system management– Definition: method where the medical staff

working through the P&T committee, evaluates, appraises, and selects from the numerous available drug products those considered most useful in patient care



• Formulary system management– Theory: a well designed formulary can guide

physicians to prescribe the safest and most effective agents for treatment of a particular condition.



• Objectives– Decrease drug cost

– Assure high quality care

– Provide information on drug products

– Provide information on organizational policies/procedures

– Development of institution specific guidelines/protocols



• Purpose for ongoing management– Removal/addition of drugs from/to the market

– Changes in hospital policies/procedures

– New clinical information available• Clinical trials

• Guidelines

• Safety



• Advantages

– Ensure quality and appropriateness of drug use

– Educational for staff regarding most effective agents

– Economic benefits

• Disadvantages– Only reduces cost

– Compromises patient care

– Limits physician prescribing authority



• Principles– Drug product selection

• Comparison of all aspects of an agent to that of similar medications.

• Should be based on scientific evidence

• Consider effectiveness, safety and cost



• Principles– Formulary Maintenance

• Addition/deletion– Newly approved agents

– New information available (i.e. safety, efficacy)

– Tracking use of nonformulary agents

• Single drug review– Compare single drug to other drugs that are similar

– Focus is on a single drug

• Therapeutic class review– Compares/contrasts all the agents in a single class

– Focus is not on a single drug


Drug Product Selection

• Development of a drug monograph

– Purpose: to evaluate various medications to ensure that patients receive drugs that are safe,therapeutically effective and cost effective



• Development of a drug monograph– Preparation

• Identify drug to evaluate

• Determine if there are similar agents on formulary

• Obtain background information– Clinical and safety information

– Indications

– Cost

– Clinical trials



• Development of a drug monograph– Components

• Summary page

• Introduction

• Pharmacology

• Pharmacokinetics

• Clinical efficacy



• Development of a drug monograph– Components (cont)

• Adverse effects

• Drug Interactions

• Cost and dosage

• Conclusion/Recommendations

• References



• Points to consider – addition to formulary– Clinical effectiveness, safety, and cost

– Comparison to similar agents

– Comparison to standard therapies

– Advantages/disadvantages

– Niche



• Therapeutic Interchange

– Definition: interchange of various TE drug products by pharmacists under pre-defined arrangements with the prescriber



• Therapeutic interchange– Elements for successful implementation

• P&T approval

• Scientific/clinical evidence

• Medical staff education

• Mechanism to implement interchange

• Maintenance



– Therapeutic interchange process• Substitute generic for brand

• Give individual agents in place of combination product

• Switch from intravenous to oral antibiotics

• Change to different agent in same class

• Interchange may be automatic or may require notification


Therapeutic Interchange

• Advantages– Reduced inventory

– MTF saves money

– Encourages compliance with formulary

• Disadvantages– Confusing to patients

– Patients may think that drugs are NOT equally effective

– Preferred product may change based on contracts


Information resources

• Local dataCHCS

CIS

Pharmacy automation system (ScriptPro, Pyxis, ect)

Prime Vendor

PDTS

• DoD level data

• PDTS

• M2


Utilizing CHCS data

Obtaining CHCS data

Capturing CHCS data in Kea™

Importing columnar reports into Excel™

Importing delimited reports into Excel™

Sorting data in Excel™

Using Access queries to clean up data

Miscellaneous tactics to clean up data before exportation including Word™ and Monarch™

29DoD Pharmacoeconomic Centerwww.pec.ha.osd.mil

Obtaining CHCS data

• Do it yourself– Canned reports (dur, cost)

– Ad hoc report

• Request from CHCS administration– Delimited with “^”

– Specify columns


Capturing CHCS data in Kea™

• Print report to “spool”– Command policy (i.e., after 2200)

– Big report take longer

• Print spooled report (PSR) – don’t print yet!

• Set Kea to “capture incoming data”

• Select file location and name

• Set Kea to “end capture”


Importing text reports into Excel™

• Open Excel• File, Open, (change file type to .txt)

• Import text wizard– Columns

– Delimited


Sorting data in Excel™Generic Name AHFS Description # RX Avg Qty per Rx Avg DS Total $ Utilizers

SIMVASTATIN HMG-COA REDUCTASE INHIBITORS 4912 83.94 80 $221,617.65 4343CLOPIDOGREL BISULFATE MISCELLANEOUS THERAPEUTIC AGENTS 709 81.34 80 $161,008.46 615FLUTICASONE/SALMETEROL SYMPATHOMIMETIC (ADRENERGIC) AGENTS 830 128.67 64 $142,101.09 678

ALENDRONATE SODIUM MISCELLANEOUS THERAPEUTIC AGENTS 1144 13.81 72 $127,977.42 1011RABEPRAZOLE SODIUM PROTON-PUMP INHIBITORS 1965 87.54 77 $110,281.04 1722

GABAPENTIN MISCELLANEOUS ANTICONVULSANTS 548 169.34 56 $101,221.12 410MONTELUKAST SODIUM MISCELLANEOUS THERAPEUTIC AGENTS 744 66.48 64 $82,180.50 620ESTROGENS,CONJUGATED ESTROGENS 1261 85.69 75 $67,273.60 1102

SERTRALINE HCL ANTIDEPRESSANTS 698 67.89 63 $67,003.02 553ROSIGLITAZONE MALEATE THIAZOLIDINEDIONES 489 92.27 75 $64,118.43 409

FEXOFENADINE HCL SECOND GENERATION ANTIHISTAMINES 740 92.4 59 $63,657.53 685AMLODIPINE BESYLATE DIHYDROPYRIDINES 879 84.7 79 $62,009.03 750

BLOOD SUGAR DIAGNOSTIC DIABETES MELLITUS 1338 155.53 46 $61,530.61 1043IRBESARTAN ANGIOTENSIN II RECEPTOR ANTAGONISTS 611 84.91 81 $56,863.22 522

VENLAFAXINE HCL ANTIDEPRESSANTS 451 80.77 61 $52,575.20 326ZOLPIDEM TARTRATE MISC. ANXIOLYTICS, SEDATIVES & HYPNOTICS 754 28.95 27 $44,548.55 466

FLUTICASONE PROPIONATE ANTI-INFLAMMATORY AGENTS (EENT) 1605 28.86 54 $42,440.70 1380MELOXICAM NONSTEROIDAL ANTI-INFLAMMATORY AGENTS 709 67.14 58 $41,935.31 632

RAMIPRIL ANGIOTENSIN-CONVERTING ENZYME INHIBITORS 662 88.54 77 $41,006.34 552LANSOPRAZOLE PROTON-PUMP INHIBITORS 754 78.27 70 $37,646.15 649

ESTROGEN,CON/M-PROGEST ACET ESTROGENS 158 74.43 73 $37,142.26 139BUPROPION HCL ANTIDEPRESSANTS 377 97.02 47 $36,553.85 288

INSULIN GLARGINE,HUM.REC.ANLOG INSULINS 346 29.19 43 $35,332.51 250MEDICAL SUPPLIES DEVICES 1354 170.75 46 $30,333.90 947

EZETIMIBE MISCELLANEOUS ANTILIPEMIC AGENTS 259 76.9 73 $27,967.99 226CITALOPRAM HYDROBROMIDE ANTIDEPRESSANTS 353 55.94 64 $26,995.95 281

TERBINAFINE HCL ALLYLAMINES 112 42.64 41 $24,819.27 83AMLODIPINE BESYLATE/BENAZEPRIL DIHYDROPYRIDINES 221 86.4 77 $24,693.04 191

RALOXIFENE HCL ESTROGEN AGONIST-ANTAGONISTS 198 82.17 81 $24,189.81 183LISINOPRIL ANGIOTENSIN-CONVERTING ENZYME INHIBITORS 2656 91.04 80 $23,824.91 2290

METFORMIN HCL BIGUANIDES 1454 187.63 77 $23,730.35 1212ALBUTEROL SULFATE/IPRATROPIUM SYMPATHOMIMETIC (ADRENERGIC) AGENTS 390 35.92 52 $23,529.57 317

TOLTERODINE TARTRATE GENITOURINARY SMOOTH MUSCLE RELAXANTS 237 74.68 72 $23,490.90 210AZITHROMYCIN MACROLIDES 779 8.18 9 $20,360.54 735

SUMATRIPTAN SUCCINATE MISC. CENTRAL NERVOUS SYSTEM AGENTS 236 13.92 26 $19,077.60 163METHYLPHENIDATE HCL ANOREXIGENICS;RESPIR.,CEREBRAL STIMULANT 280 63.98 47 $18,216.34 169

GLYBURIDE/METFORMIN HCL SULFONYLUREAS 390 221.95 78 $17,897.66 319CLONIDINE HCL CENTRAL ALPHA-AGONISTS 406 105.22 71 $17,709.98 326DILTIAZEM HCL MISC. CALCIUM-CHANNEL BLOCKING AGENTS 727 88.12 80 $17,513.96 619

AMOX TR/POTASSIUM CLAVULANATE PENICILLINS 469 53.28 11 $16,580.31 430OLOPATADINE HCL ANTIALLERGIC AGENTS 256 7.81 40 $15,583.44 216

LATANOPROST MISCELLANEOUS EENT DRUGS 393 4.69 55 $15,372.95 283FLUTICASONE PROPIONATE ADRENALS 215 20.38 46 $15,343.73 178

GLIPIZIDE SULFONYLUREAS 671 131.44 77 $15,171.19 547PAROXETINE HCL ANTIDEPRESSANTS 330 64.76 65 $14,212.90 267

NIFEDIPINE DIHYDROPYRIDINES 455 90.6 83 $14,112.43 402OLANZAPINE ANTIPSYCHOTIC AGENTS 43 77.09 52 $13,332.15 26CETIRIZINE HCL SECOND GENERATION ANTIHISTAMINES 476 183.85 35 $13,215.22 347

QUETIAPINE FUMARATE ANTIPSYCHOTIC AGENTS 116 84.88 42 $12,544.25 66RISPERIDONE ANTIPSYCHOTIC AGENTS 58 92.79 42 $12,526.56 36


Obtaining DoD level data

• PDTS– PDTS request: http://www.pec.ha.osd.mil

– PDTS training

• M2– Command authorized user


• Outline the steps in developing this process improvement using the FOCUS-PDCA model


Example P&T Process improvement

• Wanted to improve error reporting, including the reporting of near miss errors.

• MTF filled an average of 33,000 prescriptions per month between Oct 02 and Jul 03

• During this time period an average 4.1 errors/month were documented.

• No near miss errors were documented


Definition of a Medication Error

"A Medication Error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing; order communications; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use."*

Source: The National Coordinating Council for Medication Error Reporting and Prevention

(NCC MERP), 1995.


Types of errorNo Error A Circumstances or events that have the capacity to cause error.

Error, No Harm

B An error occurred but the error did not reach the patient (An "error of omission" does reach the patient).

C An error occurred that reached the patient but did not cause patient harm.

D An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm.

Error, Harm

E An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention.

F An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization.

G An error occurred that may have contributed to or resulted in permanent patient harm.

H An error occurred that required intervention necessary to sustain life.

Error, Death

I An error occurred that may have contributed to or resulted in the patient's death.

Near Miss

Miss


P&T Process

• Studied current process

• Identified areas of needless complexity or redundancy

• Looked at outcomes and the best way the process should work

• Considered factors such as cost restraints, expandability and maintainability


P&T Discoveries

• Current process for reporting errors was too time consuming

– All reports were documented on a written report

– Routed through chain of command

• Felt many people didn’t document errors due to fear of repercussions from chain of command and/or didn’t want to bother with the hassle of filling out a “report”


P&T Collaboration

• Team assembled from pharmacy personal, Risk Management, Performance Improvement and PIPA.

• Goal was to improve process for reporting errors by eliminating fear of reporting and making it easier to report errors.


Plan the Process Improvement

• New process was instituted for reporting errors.

• Points of contacts identified at all pharmacies to facilite the reporting of errors into MedMarx

• New forms created

• Staff trained


Do the Improvement, Collect Data, Analyze

• Med errors measured pre and post

• Pharmacy staff entered errors into MedMarx

• Problems encountered:

– Required continuous awareness training

– Staff deployment and turnover


MTF Medication Errors

0

20

40

60

80

100

120

140

Feb-02

Apr-02

Jun-02

Aug-02

Oct-02

Dec-02

Feb-03

Apr-03

Jun-03

Aug-03

Oct-03

Dec-03

Feb-04

Apr-04

Jun-04

Aug-04

Oct-04

Dec-04

Near miss

Miss

Near missBenchmark

Start of FOCUS PDCA

New Process Implemented


0

500

1000

1500

2000

2500

3000

3500

Feb-02

Apr-02

Jun-02

Aug-02

Oct-02

Dec-02

Feb-03

Apr-03

Jun-03

Aug-03

Oct-03

Dec-03

Feb-04

Apr-04

Jun-04

Aug-04

Oct-04

Dec-04

Miss

Near Miss

Near MissBenchmark

Ninety-One MedMarx Ambulatory Care Facilities (All minus MTF)


0

200

400

600

800

1000

1200

Feb-04

Mar-04

Apr-04

May-04

Jun-04

Jul-04

Aug-04

Sep-04

Oct-04

Nov-04

Dec-04

Jan-05NHCC Data

National Data (91 AmbulatoryCare Facilities, Minus NHCC)

All Errors reported from Ambulatory Care Facilities in MedMarx

MTF

promoting high quality, cost effective drug therapy throughout the military health system the basics...

Documents

meeting slide

mtf pt slide

chairperson slide

drug monographs

pt agenda

drug use actions

effective drug distribution

medical staff liaison