MUE program works well, following these principles
Key is using descriptive research
Hospital pharmacists and pharmacy directors are not always comfortable conducting medication use evaluations, although they recognize the need for these.
"The level of expertise and comfort with doing it is all over the board," says Geoffrey C. Wall, PharmD, FCCP, BCPS, CGP, an associate professor of pharmacy practice at Drake University in Des Moines, IA, and an internal medicine clinical pharmacist at Iowa Methodist Medical Center, also in Des Moines.
"Brand new pharmacists, fresh out of their residency, may have participated in a medication evaluation program, but they're sketchy on doing it, and there are other hospital pharmacists who are experienced with doing four or five of these per year," Wall says.
One strategy is to create a suitable medication use evaluation (MUE) instrument and to establish a process for conducting MUEs.
Whether pharmacists have little or a lot of experience, Wall suggests they could improve their medication use evaluation process by following these tips:
• Carefully review available guidelines: The American Society of Health-System Pharmacists (ASHP) has very good guidelines for conducting these evaluations, Wall says.
The "ASHP Guidelines on Medication-Use Evaluation," published on-line at www.ashp.org, suggest MUEs follow 14 steps, including the following:
- Establish organizational authority for the MUE process;
- Develop screening mechanisms (indicators) for comprehensive surveillance;
- Set priorities for in-depth analysis of important aspects;
- Inform health care professionals in the practice setting about objectives and expected benefits;
- Establish criteria, guidelines, treatment protocols, and standards of care for specific medications and processes;
- Educate health care professionals to promote use of these criteria, guidelines, etc.;
- Establish mechanisms for timely communication;
- Initiate the use of MUE criteria, guidelines, etc.;
- Collect data and evaluate care;
- Develop and implement plans for improvement of the medication use process;
- Assess the effectiveness of actions taken and document what's done;
- Incorporate improvements into criteria, guidelines, etc.;
- Repeat cycle of planning, evaluating, and taking action for ongoing improvement;
- Regularly assess effectiveness of MUE process and improve as needed.
• Target drugs with high cost, high safety concerns: Pharmacy directors should have certain drugs on their radar because of their high costs and safety issues, Wall suggests.
For instance, when drotrecogin (Xygris®) first was marketed about 7 years ago, it was a breakthrough therapy for reducing mortality from severe sepsis. It's cost was high, reaching more than $10,000 per course of treatment, Wall notes.
"Right away, that cost raises it on the radar," he explains. "Because it's a really expensive drug, we need to make sure it's used right."
Plus there were concerns about safety because the drug has anticoagulant affects, he adds.
"People in intensive care units were saying, 'We need some sort of way of making sure we're monitoring [drotrecogin] patients and making sure only the right patients receive these drugs, and to make sure we don't see too many serious adverse events,'" Wall says.
It should be a simple process for pharmacy directors to identify these types of drugs for MUEs, Wall says.
"It's easy to say we'll evaluate the drugs that are expensive, that have safety concerns, and that have efficacy issues, where existing medications might be more efficacious," Wall says. "Those are hot-ticket drugs."
If a new drug is expensive, but not a safety concern, then it's important to ask if this fourth or fifth drug in a class has any benefits beyond what existing, lower-cost drugs in its class have, he adds.
• Report outcomes to appropriate authorities: "The Joint Commission [of Oakbrook Terrace, IL] requires that we report this information to a pharmacy and therapeutics committee," Wall says. "We say, 'We've performed an MUE on this drug, and this is what we found, and based on what we found we think it might be a good idea to put restrictions on the use of the drug.'"
Restrictions could include taking the drug off of the formulary or to restrict the drug's use to certain physician specialists, he adds.
"Then in 6 months or 1 year later, we need to see if they made the changes or if the changes had the effect we desired," Wall says. "The most important piece is collecting the data."
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