Computer-guided academic detailing as part of a drug benefit program.

A service for identifying opportunities for drug cost savings in managed care plans and intervening by giving drug information to physicians is described. A clinical pharmacy company developed a computerized drug-use-review program to (1) identify and track variances in prescribing from drug-use criteria, (2) formulate plans for correcting the variances, and (3) document the impact of those interventions on drug costs. The software program weights prescriptions claims data against drug-use criteria to identify opportunities to save money. Savings opportunities for drug costs are defined as the net difference between the cost of the prescription claim and the lower, criteria-based cost. Episodes of potential savings are grouped by variables such as drug, physician, patient, and pharmacy, and each group is characterized by its total potential for cost savings. The groups are ranked to identify drug therapy problems that most contribute to the cost of medication misuse to the client. Pharmacists counsel identified physicians and enter the responses into a database for economic analyses. From September through December 1993, the software program was used to review 167,684 prescription claims totaling $4,368,576 in drug expenditures for enrollees in Pennsylvania's Pharmaceutical Assistance Contract for the Elderly program. Potential drug cost savings totaling nearly $280,000 were identified. Academic detailing by the company's pharmacists resulted in a saving in drug costs of more than $12,000 per month for the first three months after the detailing. Pharmacists at a clinical pharmacy company decreased drug costs for a managed care organization by using a software program to identify the drug costs with the greatest potential for savings and the physicians associated with those costs; the physicians were targeted for academic detailing.

Computer-generated reports for monitoring variances in the drug budget.

A computerized pharmaceutical-purchasing cost-management system that can be used to monitor variances in the drug budget is described. Variance reports on inflation, volume of drugs used, and changes in inventory are generated monthly to determine whether the pharmacy is operating within its budget. The reports are processed on an IBM personal computer with the use of a dBASE-III management software package. The price and quantity of each drug, as specified in the standard drug budget, are entered into the system; using approximately four hours per month is required for entry of the quantities and prices of drugs received as noted on the invoice. Variances in the budget are reviewed, and drug-use data are assessed to determine trends. Demand intensity (use per 1000 cases) is also tracked to determine the effects of educational programs on the proper use of drugs. Variance reports generated by a computerized budget-monitoring system provide the pharmacy with timely cost data that can be used to monitor the effects of drug-use guidelines and educational programs on the budget.

Evaluation of an indirect method of detecting adverse reactions to anticoagulants.

An indirect system of adverse-drug-reaction (ADR) surveillance was evaluated by determining the number of "alerting orders" for suspected ADRs in patients on anticoagulant therapy that were reported by staff pharmacists compared with those detected by an on-floor pharmacist observer. Physicians' orders for patients receiving warfarin or continuous-infusion heparin therapy were monitored during a five-week period to detect "alerting orders" that appeared to indicate the presence of bleeding or excessive hypoprothrombinemia during warfarin therapy or bleeding or thrombocytopenia during continuous-infusion heparin therapy. Alerting orders were classified as antidote, laboratory-test, and dosage-reduction orders, including "hold warfarin" orders; staff pharmacists were taught to detect these orders through inservice-education programs and the use of a training manual. The on-floor observer detected alerting orders through daily monitoring of all study patients' charts and evaluated suspected ADRs using predefined criteria. A total of 1622 physicians' orders were written for 79 patients. Staff pharmacists detected significantly fewer alerting orders than did the on-floor observer (76 versus 273). Also, staff pharmacists reported as alerting orders 21 physicians' orders that did not meet alerting-order criteria. Staff pharmacists reported at least one alerting order for 52 of the 75 patients who had alerting orders identified by the on-floor observer. The use by staff pharmacists of "alerting orders" was not an effective method of detecting anticoagulant-drug adverse reactions when compared with the performance of an on-floor concurrent monitor.

Drug-use review and risk management.

The concept of a combined drug-use-review (DUR) and risk-management program is discussed. Traditionally, hospital quality-assurance efforts addressed issues of patient care while risk management dealt with hospital liability by ensuring patients' custodial safety. Because most malpractice claims result from negligence in patient care, an integrated approach to quality assurance and risk management is appropriate. One of the first steps in improving patient care and reducing hospital liability is prevention of avoidable, medically related patient injuries. Studies show that many medical injuries are related to drug exposure. Concurrent comparison of medication orders and administration with selected process criteria could provide early detection and prevention of many drug-related episodes.

Audit of phenytoin prescribing for outpatients.

Phenytoin prescribing for outpatients was audited to determine if it had any deficiencies and to identify the incidence of toxicity. A pharmacy audit committee developed process and outcome criteria for phenytoin prescribing. The retrospective audit involved 45 patients (age, 14-72 years) who had regular contact with a seizure clinic for a two-year period. Only one unjustified therapeutic variation existed according to the criteria outlined for the audit. The incidence of phenytoin toxicity was approximately 38%, but all of the patients received acceptable clinical management.

Audit of lidocaine use.

An audit of lidocaine use in critical-care areas of a hospital is reported. Fifty adult patients for whom lidocaine was prescribed were admitted to the study; 31 were men. Using process, outcome, and complication criteria, the investigators reviewed the patients' medical records. If a deviation from accepted criteria was found, a medical audit committee (composed of physicians) reviewed the records and decided if the deviation was warranted. The audit results showed good compliance with the established criteria. Some minimal deficiencies were found in how lidocaine administration was initiated (6%), when a constant infusion was begun (12%), the rate of constant infusion (2%), and converting to oral therapy (2%). There was substantial deviation from criteria when ventricular arrhythmias recurred during lidocaine therapy. No major deficiencies in management of lidocaine toxicity were found. Recommendations that resulted from the audit are discussed.

Multidisciplinary audit of digoxin.

Use review of digoxin as part of a medical care evaluation study in a hospital is described. This drug audit within the hospital's quality assurance program used a multidisciplinary approach. The study was designed to measure the incidence of digoxin toxicity, evaluate monitoring practices for digoxin use and evaluate the adequacy of digoxin dosing patterns. Forty-eight patients were involved. Results indicated that some patients were not adequately assessed in regard to renal function and digoxin serum level. Further, there was a 17% incidence of digoxin toxicity. Studies such as this give pharmacists an opportunity to use their knowledge of proper drug use through a structured hospital program.

Pharmacy audit: an aid to continuing education.

Participation by pharmacists in drug-specific reviews of patient care is discussed. Criteria for drug usage review are illustrated along with data resulting from a comparison study of care using such criteria. Audit procedures are adapted from retrospective audit procedures published by the Joint Commission on Accreditation of Hospitals. Recommendations for improving the deficiencies identified in the drug usage review include the use of a drug-specific protocol for use in a continuing education seminar.

Quality of care evaluation applied to assessment of clinical pharmacy services.

Drug information supplied in a clinical setting was evaluated to determine the quality of care provided by a group of clinical pharmacists. Both process and outcome were assessed to determine the pharmacists' effectiveness in supplying clinical pharmacy services as well as to determine the relationship between these services and patient outcomes. Evaluation was conducted by a group of five physicians and the coordinator of the clinical pharmacy program. The method of evaluation seemed to contain a very high degree of interviewer reliability. Results indicate a moderate correlation, significant beyond the 0.01 level, between intermediate outcomes and the clinical pharmacy care process. The review group judged approximately three-fourths of the drug information communications as having at least a "significant" potential for benefiting the patient. Outcome measurement indicated, however, that only 14.5% of these communications were judged as actually benefiting the patient while 25% were judged as probably benefiting the patient.