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| Journal of the New Zealand Medical Association,
28-January-2005, Vol 118 No 1208
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Quality use of medicines activities in New Zealand hospitals
from 2000 to 2002
June Tordoff, Pauline Norris, Julia Kennedy, David
Reith
Quality Use of Medicines (QUM) in New Zealand and Australia
evolved from the World Health Organisation (WHO) statement on rational drug
use.1 This stated that ‘Rational use of
drugs demands that the appropriate drug be prescribed, that it be available at
the right time at a price people can afford, that it be dispensed correctly, and
that it be taken in the right dose at the right intervals and for the right
length of time. The appropriate drug must be effective, and of acceptable
quality and safety’.
From the 1980s onwards, ‘rational use of
medicines’ became a prominent theme, promoted by the WHO, the
International Network for Rational Use of Drugs, and national
governments.1–3
In 1992, in Australia, consumer and healthcare
organisations’ concerns about the effective and safe use of medicines led
to QUM becoming the fourth arm of their National Medicines
Policy.4 (Others were: ensuring the
availability of safe, high-quality, effective medicines; providing equity of
access to cost-effective medicines; and maintaining the viability of the
pharmaceutical industry).
The objectives of Australia’s QUM policy were to
achieve: judicious selection of management options (use of medicines only where
appropriate); appropriate choice of medicine and dosage regimens (choice of the
most effective medicine whilst considering benefit, risk, cost, etc); safe use
of medicines (minimising misuse, overuse, and underuse; and taking action to
solve medication related problems such as adverse
effects).4
In New Zealand, health professionals’ concerns about
the safe and effective use of medicines have resulted in hospitals and other
organisations undertaking activities to promote
QUM.5–7
In 1993, the Pharmaceutical Management Agency (PHARMAC) was
established in New Zealand to manage the list of pharmaceuticals subsidised by
the Government for use in the community. In February 2002, PHARMAC launched the
National Hospital Pharmaceutical Strategy (NHPS) to manage the purchasing of
pharmaceuticals in New Zealand hospitals. The NHPS included ‘promotion of
Quality in the Use of Medicines’ as one of three main areas of
focus.8 (Others were the management of prices
for pharmaceuticals, and the assessment of new medicines.)
The NHPS proposed the development of a national programme
for QUM in New Zealand hospitals with some activities centrally-coordinated by
PHARMAC. During a consultation exercise, stakeholders raised concerns at the QUM
proposals, and at other proposals within the
Strategy.8 The present study has been
undertaken therefore, independently of PHARMAC, to determine the level of QUM
activity in New Zealand Hospitals prior to the introduction of a centralised QUM
strategy, and to ascertain attitudes to the introduction of such a
policy.
Aims
MethodA questionnaire was developed
and administered to chief pharmacists at all 30 New Zealand hospitals with at
least one pharmacist onsite. The topics included in the questionnaire were:
guideline development; drug utilisation reviews (DURs); dissemination of drug
expenditure data; hospital formularies; bulletins on medicine use; campaigns to
improve prescribing; sources of economic information; and staffing levels for
drug utilisation and drug information activities.
In the questionnaire, Drug Utilisation Reviews (DURs)
were defined as audits of medicine use undertaken in clinical areas, where data
is collected on the use of particular medicines, plus data on relevant patient
factors. Decision-makers were defined as those persons given authority to decide
whether/how particular medicines could be used in clinical areas—e.g.
senior managers/clinical leaders/advisory committees.
Drug Utilisation activities were defined as assessment
of new medicines, formulary and guideline development, bulletin writing,
education campaigns, and DURs. Drug information activities were not specifically
defined as they are usually understood to be the provision of information on
drugs in response to specific requests. Some aspects of QUM (such as systems for
monitoring adverse drug events and clinical pharmacy interventions) were
considered to be beyond the scope of this study.
Four senior pharmacists pilot tested the questionnaire
for face validity, ambiguity, and time to complete. In addition, the
questionnaire was reviewed by a health-policy researcher and a statistician. The
questions were open, closed, or continuous. For the continuous questions,
respondents were asked to give their opinion on a scale of 1–6 where
‘1 = always’ and ‘6 = never’. Hospitals and chief
pharmacists were identified from a list published by the New Zealand Healthcare
Pharmacists’ Association. The questionnaire was posted to all 30 chief
pharmacists in June 2002. To improve the response rate, telephone contact was
made with respondents prior to posting the questionnaire and at
follow-up.
For analysis, hospitals were classified as tertiary (6
hospitals), secondary (12), or rural/special (11). Tertiary hospitals were those
with all specialities onsite; secondary, most specialities onsite but some
visiting specialists; rural/special hospitals were small hospitals with only
visiting specialists, or hospitals for a special group of patients (e.g.
psychiatric). The New Zealand Ministry of Health provided advice and validated
the group allocations. Hospitals were further divided into independent hospitals
(undertaking QUM activities independently) and hospitals under the auspices of a
local tertiary hospital. Results are presented as the total activity and
activities undertaken by independent hospitals.
Categorical data were tabulated. Summary statistics
were calculated for continuous data and medians were compared using the
Kruskal-Wallis test.9 Regression analysis was
undertaken for several variables (number of: DURs undertaken, bulletins
developed, campaigns undertaken) against staff resources for clinical pharmacy,
drug utilisation, and drug information per 100
beds.9 For the Kruskal-Wallis test and
regression analysis, a level of p<0.05 was considered statistically
significant.
ResultsThe questionnaire was sent to 30
hospitals and it was completed by 29 of them, a response rate of 96.7%. One
pharmacist declined to answer the questionnaire because their hospital was
affiliated to a larger hospital where policy decisions were made. In addition to
this hospital, three other hospitals undertook QUM activities under the auspices
of a local tertiary hospital, and 26 hospitals were considered
independent.
For the independent hospitals, a total of 64 DURs were
undertaken over the 2-year period (Table 1). DURs were undertaken in a greater
proportion of tertiary hospitals, than in other hospitals. Reviews were
undertaken on 29 medicines/groups, but mainly on antibiotics. Respondents
indicated that (resources permitting) they would like DURs to be undertaken on
all medicines with safety/cost concerns. Thirteen hospitals reported that a
total of 103 bulletins with information on medicine use have been produced since
July 2000 (median 6, range 0–24; Table 1). Bulletins were produced
predominantly in tertiary hospitals.
Fifteen respondents reported that 73 hospital-wide campaigns
(to improve an aspect of prescribing) were undertaken. No such campaigns were
reported by the remaining 11 independent hospitals. Three hospitals linked to a
tertiary hospital reported 3 campaigns. Of the 29 hospitals, 25 hospitals had
hospital formularies (86.2%). Nineteen (63.3%) of these hospitals had their own
formulary, whilst six used a formulary from a nearby tertiary hospital (Table
2). All formularies had a preferred medicines list (100%), and the majority had
antimicrobial guidelines (76%), and policies relating to medicine use (72%).
Fewer hospitals had paediatric guidelines (31%) or acute
medical guidelines (27.6%). Only four had emergency resuscitation guidelines.
All tertiary hospitals had policies related to medicines use and antimicrobial
guidelines, but fewer secondary and rural/special hospitals had these documents.
Amongst hospitals with formularies, 18 formularies (72%) had been revised in the
past 3 years. In the past 10 years, formularies have been revised more
frequently in tertiary hospitals than in other hospitals. Formularies were
issued to house surgeons, registrars, pharmacists, wards, and
departments—but less frequently to consultants compared to other doctors.
Only five hospitals issued copies to general practitioners and two to community
pharmacists.
Hospitals reported sending drug expenditure data to
financial managers, nurse managers, consultants, nurses, and
‘others’ (e.g. Medicines and Therapeutics committees [MTCs] or Chief
Executive Officers). Feedback comments were more often received from financial
managers in tertiary hospitals than from financial managers in other hospitals
(p=0.04) (Table 3).
Most respondents indicated where they would source economic
information (Table 4). The most popular response was to search the drug
literature, ask an independent source, or ask the supplier. More than a quarter
of respondents would attempt to calculate ‘numbers needed to treat’,
‘cost saving for a shorter hospital stay’, or ‘cost for an
event saved’—but only three would attempt ‘cost per life year
gained’, and only one would attempt cost per ‘quality adjusted life
year’.
Overall, decision-makers only infrequently requested the
development of guidelines/criteria for use for medicines, except if there were
safety/cost concerns (Table 5). Regarding DURs, decision-makers rarely requested
these (with the exception of decision-makers in tertiary hospitals who requested
DURs for new medicines more frequently than decision-makers in other hospitals,
p=0.01). Clinicians occasionally requested help from pharmacists in developing
guidelines/criteria for use, but rarely requested DURs to audit medicine
use.
Respondents reported mixed opinions on the possible
centralised coordination of some QUM activities (Table 6). Three respondents
reported ‘Yes’ they would use guidelines/criteria for use for new
medicines if developed by PHARMAC (four if developed by an independent group).
Providing there was agreement with the supporting evidence, 19 respondents would
use guidelines if developed by PHARMAC, and 20 if developed by an independent
group. Of the other respondents, 7 would only use guidelines if in total
agreement with their own organisation (and if developed by PHARMAC), or four
only if developed by an independent group. For the fourth option, one hospital
would not accept guidelines developed by an independent group, but no hospital
chose this option with respect to PHARMAC.
Two hospitals reported ‘Yes’ they would use DURs
if developed by either PHARMAC or an independent group (Table 6). Providing they
agreed with the design and supporting evidence, 20 hospitals would use DURs if
developed by PHARMAC, and 21 hospitals would use DURs if developed by an
independent group. One tertiary hospital would prefer to develop their own DURs.
Six hospitals (5 if developed by an independent group) reported they had
insufficient staff to participate in DURs if developed by PHARMAC.
Two-thirds of hospitals provided a drug utilisation (DU)
service with 10.1 Full Time Equivalents (FTE) staff employed, 6.9 FTE in
tertiary hospitals. All hospitals provided a drug information service with 10.7
FTE employed, 7.5 FTE in tertiary hospitals. Two-thirds of hospitals provided a
clinical pharmacy service to the majority of wards (one-third to less than 50%
of wards). Regression analysis indicated an association between an increase in
staff-time (FTEs/100 hospitals beds) and an increase in DURs undertaken, for
both clinical pharmacists and DU+DI pharmacists (p<0.05). In addition, there
was an association between an increase in clinical pharmacist staff-time and an
increase in the number of campaigns undertaken (p<0.05). Neither group
demonstrated any association with bulletins produced.
DiscussionThe present study indicates that a
wide range of activities to promote QUM were being undertaken in New Zealand
hospitals: Drug Utilisation Reviews and campaigns were undertaken, formularies,
bulletins and drug expenditure data were disseminated. The type of DUR activity
in New Zealand hospitals was similar to that reported in other
countries.12–16 The present study did not
examine outcomes from the DURs undertaken in the period, but previous research
indicates that DURs and feedback are an effective method of improving the
quality use of medicines.7,17,18
The present study examined the level of activity in
educational strategies (bulletins and campaigns) but not the quality or effects,
of these strategies. Surveys from other countries also report the use of these
strategies.13,16 Bulletins may be less
effective at influencing medicine use than complex interventions such as
educational outreach visits and local opinion
leaders.19,20 Further research could determine
the use of such complex strategies in New Zealand hospitals.
The dissemination of drug expenditure information may assist
in the targeting of activities to promote QUM. In common with other countries,
the present study reports that hospital pharmacists send drug expenditure
information to key members of hospital
staff.12,14–16 Financial managers in
tertiary hospitals appear to give more feedback then financial managers in other
hospitals. In addition, most respondents had some knowledge of where to source
pharmacoeconomic information—although use of this information in
decision-making was not examined.
Researchers in other countries report the use of
pharmacoeconomic information in formulary decision-making in
hospitals.13,16,22,26 Other researchers have
identified barriers to the use of this information - lack of high-quality,
concise, generalisable information from a trusted source and the need for
training and education in pharmacoeconomics for
decision-makers.27,28 These barriers may also
apply in New Zealand.
In common with reports from other counties, most New Zealand
hospitals used a formulary13,15,21–25 the
majority of formularies having a preferred medicines list, policies relating to
medicine use, and antimicrobial guidelines. Given the growing level of
antibiotic resistance, more hospitals may consider developing antibiotic
guidelines in future.
Information on the contents of hospital formularies in other
countries is limited: Thurmann et al (Germany 1997) reported that 80% of
hospital formularies had antimicrobial treatment guidelines; Fijn reported that
64% of Dutch hospitals had antibiotic policies and policies on medicine
use.24,25 Regarding formulary revision, the
present study reported 72% of New Zealand hospital formularies have been revised
in the past 3 years compared with 46% of hospitals surveyed in the Netherlands
in 1999.25 Fewer hospitals in New Zealand
issued formularies to GPs or community pharmacists (≤20%) compared with
hospitals in the Netherlands (31%).24 Expense
may be a major barrier to more widespread distribution. This may be overcome in
future as electronic versions become available.
Studies in other counties indicate that guidelines for
appropriate use of specific medicines are used in hospitals and appear to be
reviewed/approved by drug and therapeutics
committees.12,13,15,16,22–24 The present
study indicated that guidelines were used in New Zealand hospitals but that
whilst decision-makers and clinicians had some interest in the development of
guidelines/criteria for use (particularly if there were safety/cost concerns),
they rarely requested DURs. This suggests that policy-making is of some
importance to these groups, but that audit of implementation may be seen by them
as less important. Decision-makers in tertiary hospitals, requested DURs for new
medicines more frequently than decision-makers in other hospitals, perhaps
reflecting a stronger commitment to the ‘quality-audit’
cycle.
The study reported some resistance to the centralised
development of guidelines and DURs with up to 24% of hospitals requiring total
agreement with own guidelines, and 20% requiring agreement with the design and
evidence-base for DURs. Since guidelines and DURs are linked (DURs are usually
undertaken to assess prescribing before and after the launch of guidelines),
resistance to both is not surprising.
Attempts to centralise guideline and DUR development are an
example of the New Zealand Government maintaining some central control
whilst devolving responsibility for healthcare provision to the individual DHBs.
There are indications that issues of central versus local control are causing
increasing tension in the New Zealand health
system.10 The majority of respondents in the
present study indicated a preference for local agreement before participating in
a centralised program of activities. This is consistent with earlier research
that indicated that policies are more effectively implemented when there is
local involvement in their development.11
Nationwide involvement in guideline development with assistance from a
nationally-funded independent centre may be more acceptable to
hospitals.
In New Zealand, the majority of staff-time for drug
utilisation, drug information, and clinical pharmacy was allocated in tertiary
hospitals. There was a significant correlation for the number of DURs undertaken
and staff-time (FTEs/100 hospital beds) for clinical pharmacists and DU+DI
pharmacists. Since audit-feedback (DURs) is reported to be an effective method
of changing prescribing,19,20 an increase in
staff-time dedicated to these activities could be recommended. Furthermore, a
study in the US indicated that hospitals providing DI and DU services show
reduced overall costs of care.29
It is possible that some QUM activities in clinical areas
may have been missed by this survey. A survey of clinical directors may have
identified more activity. However, the survey was undertaken by chief
pharmacists for two reasons: firstly because they were considered to have a
hospital-wide view of QUM activities, and secondly to avoid double-counting of
activities. Another limitation could be that the numbers of each staff group
sent drug expenditure figures may have influenced the number of feedback
comments received.
The information collected in the survey was mainly factual,
but the accuracy of responses relied on good record-keeping or memory—e.g.
number of bulletins produced, campaigns, and DURs undertaken. It is possible
there may be some positive recall bias in the numbers of bulletins and campaigns
reported, since detail of content was not sought. The estimates of numbers of
DURs should be more accurate since details of the DURs were requested in the
survey.
ConclusionThis survey indicates that a wide
range of activities to promote quality use of medicines were undertaken in New
Zealand hospitals in the period 2000 to 2002. In general, more activities per
hospital were undertaken in tertiary and secondary hospitals where there was a
greater number of clinical pharmacists and pharmacists dedicated to DU and DI
activities. An increase in staff-time for clinical pharmacy, DU, and DI is
recommended for hospitals in New Zealand to assist in the promotion of QUM.
There may be some resistance to accept centralisation of guideline and DUR
development and local issues and staff resources will need to be given
consideration.
Author information:
June Tordoff, Lecturer, School of Pharmacy, University of Otago, Dunedin;
Pauline Norris, Senior Lecturer, School of Pharmacy, University of Otago,
Dunedin; Julia Kennedy, Associate Professor, School of Pharmacy, University
College Cork (UCC), Cork, Republic of Ireland; David Reith, Senior Lecturer,
Dunedin School of Medicine, University of Otago, Dunedin
Acknowledgements:
The authors are grateful to the chief pharmacists responding to the survey, to
the Ministry of Health for assistance with classifying hospitals, and to the
pharmacists who took part in the focus group and pilot-testing of the
questionnaire. There were no external sources of funding for the project and no
potential conflicts of interest to declare.
Correspondence: June
M Tordoff, Lecturer in Clinical Pharmacy, School of Pharmacy, University of
Otago, PO Box 913, Dunedin. Fax: (03) 479 7034; email: june.tordoff@stonebow.otago.ac.nz
References:
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