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Dr Hepler is distinguished professor in the department
of pharmacy health care administration and director of the DuBow
family centre for research in pharmaceutical care at the University
of Florida college of pharmacy
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The advantages of a multi-level medicines management system may be fundamental and far-reaching. Beneficiaries would include patients, pharmacists, physicians and, ultimately, the entire health enterprise of a nation.
The paper (PDF 100K) by Morris, Cantrill and Bate in this issue of The Journal (see
pp682–6) describes a promising approach toward a medicines management
system. The authors used medication use performance indicators, specifically
indicators of preventable drug-related morbidity (PDRM), to stimulate
discussion of the system factors that contributed to the PDRM.
Medicines use exists on many levels, like the health care system within
which it is embedded. The levels of medicines use and health care systems
differ in their scope and detail. The patient level is the most specific
and detailed. This is the level of primary experience, eg, symptoms,
cures and quality of life for a single patient (or, at least, one patient
at a time). Outcomes at the patient level are the pre-eminent bases for
judging the appropriateness and quality of care at the other levels.
At the level of professional practice, doctors, pharmacists and nurses
provide care directly to many patients. At the organisational level,
many practices share resources and operate within a structure, for example,
a primary care organisation or a hospital. At the environmental level,
many groups and organisations work within common guidelines, standards,
rules, policies, etc. The clearest examples of environment would be laws,
cultures, and government(s). In the UK, the National Health Service is
technically a health care finance organisation but is so all-encompassing
that it has some environmental attributes. The environmental level influences
procedures in each of the more specific levels and, ultimately, the outcomes
at the patient level.
According to the NHS, the continuous improvement of prescribing and the
use of medicines is “one of the most crucial elements of health
care development, in this rapidly changing environment”. This obviously
refers to the organisational or environmental level. In contrast, the
stated objectives of medicines management are to optimise prescribing,
to identify individuals’ pharmaceutical needs and to help people
to get the best out of their medicines. Medicines management (as the
term is most commonly used) refers to the patient level, and is similar
to what I have called pharmaceutical care. In order for the overall medications
use system to function properly, the general goal of “continuous
improvement of prescribing and the use of medicines”, at an organisational
level, has to connect with the specific objectives of medicines management
or pharmaceutical care at the patient level.
Morris et al applied PDRM indicators
to an electronic patient database in a general practitioner practice.
The indicator “positives” identified instances of potential PDRM. These potential
PDRM were then discussed by the investigators and staff of the practice.
These informal discussions identified individual patient problems in
medicines use and general weakness in the system of prescribing and patient
follow-up care that had permitted the patient problems to recur. They
also indicated ways to strengthen the system that might prevent future
problems and improve outcomes.
That exercise was a somewhat informal example of continuous quality improvement.
Repeated application of the indicators within the practice would show
whether selected efforts to improve the medicines use process had been
successful. Data aggregated from many practices would provide essential
feedback to the organisational and environmental levels about processes
actually carried out, outcomes that actually occurred and how they were
related to each other and to policy.
Quality improvement is familiar in medications use as drug use review
(DUR). DUR is, however, limited in relevance and scope. It is relevant
to the practice level but does not connect it to patient outcomes. As
usually practised, DUR is limited to prescribers’ choices of therapeutic
agents. Choice of therapeutic agent, however, generally accounts for
relatively few adverse outcomes compared with inappropriate dose, patient
non-adherence and inappropriate follow up. The PDRM indicators described
by Morris et al encompass all steps in medicines management, not just
drug choice, and connect practice to outcome. They are medication-use-system
clinical performance indicators, based on accepted clinical guidelines
or expert consensus. They connect the practice level to the organisational
level.
Quality improvement and pharmaceutical care/medicines management have
a great deal in common. Both require similar processes of decisions and
actions, one from a practice or population perspective (many patients)
and the other from a patient perspective. Both quality improvement and
pharmaceutical care require (i) setting objectives, (ii) assessing progress
toward those objectives based on evidence, (iii) deciding when progress
is not satisfactory, (iv) defining problems in terms of their basic causes,
(v) identifying, evaluating and choosing alternative solutions, (vi)
recommending or implementing an intervention and (vii) following up the
intervention (which is actually a return to step i). This similarity
is significant for two reasons.
First, PDRM indicators directly link quality improvement and patient
care. In their study Morris et al identified patients with potential
PDRM. Estimating the prevalence of PDRM is important; furthermore, the
performance indicators may serve another function. The process components
of PDRM indicators can be used prospectively to identify patients who
are receiving potentially inappropriate processes of care, before a drug-related
morbidity (DRM) has time to occur. Care of those patients could be reviewed
by the pharmacist and GP and appropriate action could be taken promptly,
to prevent the DRM.
Second, pharmaceutical care and quality improvement are mutually supportive.
Pharmaceutical care is a patient-level quality improvement programme.
Perhaps pharmacy’s past approach has been incomplete. Pharmacists
have discussed pharmaceutical care as an abstract system change and then
tried to make it more concrete, tried to prove its worth, etc. Perhaps
pharmacists should also approach pharmaceutical care from the perspective
of indicator data, as Morris et al have done. This makes it obvious that
pharmaceutical care is an idea about the quality of patient care systems
rather than merely an occupational strategy.
The opportunities represented by medicines management/pharmaceutical
care (on the patient level) can be magnified and solidified by constructing
data-driven medicines management systems. These should
be integral parts of clinical governance
programmes in the NHS. The work of Morris et al has shown one promising
way forward to the goal of systematic medicines management. |
