Improving use of medicines with clinician-led use of validated clinical indicators

Use of clinical indicators with collection and monitoring of meaningful data has been recognised as important for driving improvements in the safety and quality of health care.1 Quality Use of Medicines (QUM) is one aspect of health care in which continual improvement is vitally important. QUM forms part of Australia’s National Medicines Policy and involves judicious selection of treatment options (including choice between drug or non-drug treatment and no treatment), appropriate choice of medicines when they are required, and safe and efficacious use of medicines.2

Problems with medicines use are costly and occur commonly at all stages of the medicines management pathway3 and in all health care settings. Elderly, paediatric and chronically ill patients are at particular risk of experiencing adverse drug events. In Australia, some 190 000 admissions per year are associated with medicine-related problems, costing the health care system about $660 million, and adverse events involving medicines are consistently among the most frequently reported incidents in voluntary incident-reporting systems.4 Thus, to stimulate quality improvement in this area of health care, it is critical to systematically collect meaningful data about medicines use.

Organisations such as the Australian Commission on Safety and Quality in Health Care, the Australian Council on Healthcare Standards (ACHS), the Australian Institute of Health and Welfare, the Council of Australian Governments and the National Prescribing Service are developing clinical indicators for measuring and improving the safety and quality of health care. However, QUM issues are addressed inconsistently in indicators relating to hospitalised patients — probably because medicines management is complex and multidisciplinary3 and not wholly “owned” by any one profession, specialty or discipline.

Accordingly, the New South Wales Therapeutic Advisory Group, in collaboration with the Clinical Excellence Commission, has developed Indicators for quality use of medicines in Australian hospitals (QUM indicators).5 The QUM indicators address 30 aspects of care in six areas of practice (Box), including high-risk or high-use medicines (eg, anticoagulants and antibiotics); high-risk populations (eg, paediatric patients); and high-risk clinical settings (eg, transfer from hospital to home or to another health care setting).

Many indicators are released for routine use without prior testing or validation in clinical environments, despite the recognised importance of this step.6 We undertook a rigorous development process that included systematic and structured decision making for selecting indicators; consultation with a broad range of clinicians and stakeholders; and pilot-testing in a wide variety of hospitals across Australia. Consequently, each QUM indicator meets the properties of an ideal indicator, such as content validity, face validity, clarity, comparability, measurability, remediability and usefulness.6-8 As we excluded indicators not meeting these criteria, not every area of QUM is addressed. However, our development process has ensured that all the indicators are accepted by clinicians as valid, measurable, important and useful for informing local improvements in QUM. This is likely to enhance their uptake in routine practice.

The QUM indicators are primarily designed as tools to inform quality improvement initiatives at the unit, department, or organisation level. They are process measures and provide information about the way medicines management is delivered. Improved performance in the aspects of care measured by process indicators is expected to result in improved health outcomes, as has been demonstrated by Peterson and colleagues.9

The QUM indicator manual (available at http://www.ciap.health. nsw.gov.au/nswtag/indicators.html) describes how to use the indicators to drive improvements in practice and contains detailed instructions for data collection. Using an effective improvement method (eg, drug use evaluation or clinical practice improvement)10,11 and supporting clinicians with appropriate resources and expertise can promote the use of indicators and lead to improvements over time.11

To date, implementing the QUM indicators has included incorporation of selected indicators into programs such as the Electronic Medical Record State Base Build developed by NSW Health; the ACHS Clinical Indicators program, the evaluation of the paediatric National Inpatient Medication Chart, and the National Prescribing Service national drug use evaluation program.

The indicators will evolve as their use continues. Adjustments may be needed for a number of reasons, such as clinician feedback and experience; changes in evidence and clinical practice; and alignment with other programs. For example, minor adjustments have been made to the indicators incorporated by the National Prescribing Service and the ACHS in their programs. However, changes should not be introduced without sound reasons and supporting evidence. These indicators are not designed for making comparisons between institutions (benchmarking) or for accountability purposes. If they are to be used for such purposes, further testing of their validity and reliability and appropriate modification is warranted to ensure that comparisons are fair.12

The QUM indicators will be of most use in supporting improvements in health care when data collection and feedback are incorporated into routine clinical practice in all health care settings. To facilitate uptake of the indicators and improvements in care, results must be presented in a time frame and format that is meaningful to clinicians and encourages reflection and discussion.12-15 Clinical teams must be motivated to change their practice and systems in response to results. Using indicators routinely will become easier as electronic medical records and electronic medicines management become more widespread. Appropriate allocation of resources and expertise to support data collection and design and delivery of evidence-based interventions will help.11

We encourage clinicians from all disciplines and specialties to regularly use the QUM indicators relevant to their practice, interpret results in the light of clinical expertise, and drive appropriate system improvements. The effectiveness of these indicators will ultimately be determined by demonstrated improvements in QUM over time at the local and population level.