The development and implementation of a drug utilization review program.

In response to rising drug expenditures and pressure from hospital administration to contain drug costs, the department of pharmaceutical services at The Mississauga Hospital initiated a Drug Utilization Review (DUR) Program. The main purpose of this program was to contain the escalating drug budget through identifying and correcting areas of drug misuse, without compromising the quality of patient care. This article will describe the procedures involved in developing and implementing such a DUR program at our hospital and our experience to date. Both structured and informal strategies have been implemented, which have identified factual and potential cost savings. Overall, the DUR program has been well accepted by the medical staff and hospital administration.     

A strategy to reduce drug expenditures with a drug utilization review program

This paper describes a potential strategy for implementing a Drug Utilization Review (DUR) program aimed at reducing hospital drug expenditures. The importance of this type of program is underscored by the spiraling rise in health care expenditures and the influence of a new drug technology on this rise. The program described here consists of a utilization review program for high cost drugs for which a lower cost alternative exists. An initial retrospective usage and cost analysis must be undertaken to identify those drugs which should be reviewed initially. As the DUR program progresses, additional drugs can be added to the review program. Once the drugs to be reviewed are identified, the first step is to develop usage criteria. This can be accomplished through a review of the literature and consultation with medical and other specialists. Appropriate medical administrative staff approval and endorsement of the criteria should be obtained utilizing various committee structures and other input. The pharmacy staff must also be inserviced on the approved drug usage criteria. After the criteria are finalized, staff pharmacists will contact a DUR pharmacist daily upon receipt of any physician orders for the review drugs. This pharmacist will then compare the prescribed drug use to the approved criteria and contact the prescriber when the usage appears questionable. A lower cost therapy will then be recommended when appropriate. In order to assess the impact of this intervention strategy on drug expenditures, the cost of the initially prescribed therapies must be compared to the recommended therapies. Data should also be obtained on overall drug usage and expenditures to detect shifts in therapy and drug costs. The success or failure of this concurrent DUR program will be highly dependent upon a team approach and cooperation. A program of this type could have a significant impact on hospital drug expenditures in those hospitals where it can be successfully implemented.     

Drug use review: operational definitions

A distinction is made between drug use review (DUR) studies and programs. DUR studies can be quantitative or qualitative. Quantitative studies involve the collection, organization and display of estimates or measurements of amounts of drug use. Qaulitative studies are multidisciplinary operations which collect, organize, analyze and report information on the rationality of the drug use base. A DUR program is an ongoing method of assuring the quality of drug use through the employment of standards and efforts to correct drug use not consistent with these standards; the effectiveness of corrective actions is measured.     

Impact of drug usage review on drug utilisation

Drug use review (DUR) programmes have been a component of efforts to improve prescribing practices in both the institutional and ambulatory care settings in various areas of the world. DUR provides the mechanism for developing standards, assessing current therapy, and implementing a specific intervention followed by reassessment of drug utilisation. A number of interventions aimed at improving drug prescribing practices have been included as components of the DUR process. At this time, face-to-face interaction with the prescriber has been shown to be the most effective intervention. However, DUR interventions have rarely been subjected to quality pharmacoeconomic evaluation. There is a need for future research to evaluate the effects of DUR programmes on overall healthcare outcomes.     

Impact of an aminoglycoside kinetic service on aminoglycoside use in a community hospital.

The effectiveness of an aminoglycoside monitoring service in improving the prescribing patterns of physicians in the hospital was evaluated. A drug utilization review (DUR) done as part of routine monitoring demonstrated a deficiency in eight of 19 elements based on national DUR standards. An aminoglycoside monitoring program developed by the Pharmacy Department was then implemented. A comparative DUR demonstrated significant improvement in five previously deficient elements, a trend towards improvement in two elements, and no change in one element. We conclude that a concurrent drug monitoring program with aggressive pharmacy participation improves prescribing patterns by physicians.     

Evaluation of amitriptyline use for depression when prescribed by internists and psychiatrists

The efforts involved in structuring and implementing a drug utilization review (DUR) program that was designed to assess the use of amitriptyline for depression when prescribed by internists and psychiatrists is described. In-depth audit criteria were used to identify deviations from the criteria for each group. An immediate goal of this amitriptyline DUR program is to apply the results of the study toward the implementation of a targeted, multifaceted educational program. The design of the DUR program should emphasize the individual needs of each of the two study groups.     

Low cost, manual drug use review of Medicaid recipients to screen prescriber and pharmacist performance.

A manual drug use review (DUR) methodology to screen outpatient prescribing which would meet the needs of large third-party programs that cannot afford elaborate computerized DUR was developed and pilot tested. A Medicaid drugs data base was used for the pilot test. A probability sample of 100 recipients over a three-month period was selected for the DUR. The drugs for each recipient, listed by their generic composition and amount, were recorded. Then a priori, explicit, screening criteria were developed for these generics. These criteria delineated drugs of choice, daily dose and refill patterns and, as appropriate, therapy length, drug holidays, and disease-drug and drug-drug interactions. Only 11% of recipients had prescribing patterns which passed all the screens. The most frequent screening failure was due to the prescribing of a drug which was not a drug of choice. In nearly all of the cases which failed the other screens, an alert pharmacist with patient records should have noticed these problems. An analysis showed that the initial start-up cost for the manual DUR was estimated at $1053 (not including personnel fringe benefits); for subsequent quarterly review, the cost was estimated to be about $530. The project showed that manual DUR can effectively and efficiently screen prescribing in a large third-party program.     

Drug utilization review across jurisdictions – a reality or still a distant dream?

Objective There is a perception that many drug usage evaluations do not widely influence prescribing behaviour. The aim of this study was to critically evaluate recent journal articles which fit the Medline definition for Drug Utilization Review (DUR) and which also cover multiple healthcare sites. Methods PubMed (National Library of Medicine, NLM) (2003, 2004) was searched using the MeSH topic ‘drug utilization’. Retrieved studies were evaluated to ascertain those describing a DUR (measuring drug use against specific criteria). These were subdivided according to whether the DUR was conducted at one site or across many. The multi-centre DURs were critically reviewed, including evaluating whether all phases of a quality cycle were completed and determining aspects of design such as whether the study was prospective or retrospective, any interventions conducted and provision of feedback. Results A total of 646 unique articles were retrieved. Of these, 495 (77%) did not meet the definition for DUR, while 151 (23%) articles did. Thirty-five (5%) described English language multi-centre DURs; ethics approval was obtained in ten of these and 18 were carried out retrospectively. In all 35 studies some comparator or standard was used, but only eight conducted an intervention and only three provided feedback to the prescribers. Conclusion Most DURs were not conducted across a number of centres. Of the recent published multi-centre DURs most presented only an initial audit and did not complete the quality cycle with feedback, intervention and re-audit. To widely influence prescribing behaviour, the full cycle is required with involvement of as many sites as possible to achieve improvements across many jurisdictions.     

Inter- and Intrarater Reliability of Retrospective Drug Utilization Reviewers

ObjectiveTo assess inter- and intrarater reliability among 23 pharmacist and physician retrospective drug utilization reviewers and to assess interrater reliability after a reviewer training session.DesignExploratory study.SettingMaryland Medicaid's retrospective drug utilization review (DUR) program.Participants23 physician and pharmacist retrospective drug utilization reviewers.InterventionsNone.Main Outcome MeasuresProfiles rated as “intervention indicated” or “intervention not indicated.” Cochran's Q test, overall percent agreement, and the unweighted kappa statistic were used in the analysis of review consistency.ResultsIntrarater reliability showed substantial consistency among the 23 reviewers; the percent agreement was 82.9% with κ = 0.66. Interrater reliability, however, was poor, with an overall agreement of 69.6% and κ = 0.16. Interrater reliability was also poor after a one-hour reviewer training session (agreement 81.8%, κ = −0.19).ConclusionThe implicit review process used in the retrospective DUR program that we evaluated was unreliable. Since reliability is a necessary but not sufficient condition for validity of an indicator of inappropriate drug use, the validity of the DUR implicit review process is in question.     

Do practice guidelines augment drug utilisation review?

Drug utilisation review (DUR) or drug use evaluation (DUE) studies or programmes are intended to detect and/or correct inappropriate drug use. Appropriateness can be assessed at 3 levels: (i) whether any medication is warranted, or whether either no therapy or nondrug therapy is preferred (level 1); (ii) assuming drug therapy is indicated, which of several alternative drugs is the preferred choice? (level 2); and (iii) appropriateness of the drug regimen, including dosage, duration, type and frequency of monitoring, and drug interactions (level 3). The traditional approach to DUR/DUE has been to begin the appropriateness evaluation after a drug is prescribed. However, changes in healthcare organisation provide the basis for a disease-management or health-maintenance approach to DUR/DUE, and practice guidelines afford a possible source for guiding such studies. We hypothesised that the latter approach to DUR/DUE would be more likely to result in evaluation of level 1 drug-therapy issues than the traditional DUR/DUE approach. We tested this hypothesis by reviewing 56 practice guidelines involving drug therapy and also reviewed research studies published from 1992 to 1996. We found that studies that used the traditional DUR/DUE approach were most likely to examine level 3 drug-therapy issues, never addressed level 1 issues, and typically evaluated adherence to provider- or study team-developed guidelines rather than published guidelines. In contrast, the disease- or health-management approach nearly always examined level 1 issues, seldom addressed level 3 issues, and almost always evaluated adherence to a published practice guideline. Regardless of the DUR/DUE approach, about 40% of studies evaluated level 2 issues. The guidelines themselves were much more likely to include recommendations about level 1 and level 2 issues than about level 3 issues; however, even when a guideline included level 2 or level 3 issues, studies of adherence to the guideline rarely assessed anything beyond level 1 issues. This suggests that guideline recommendations about level 2 and level 3 issues may be too imprecise for use in evaluative studies. The drug-information compendia, on the other hand, provide detailed recommendations about level 3 issues. Revision of drug compendia may be warranted to include recommendations about all levels of drug-therapy issues. The results of intervention studies to improve drug-therapy compliance with guidelines suggest that information provided at the time of prescribing, information presented by local health professionals and information provided with a large amount of provider contact may be more likely to demonstrate significant improvements in drug therapy. We conclude that practice guidelines are a useful resource for augmenting DUR/DUE but that challenges to optimising their use include whether they can be kept current, acceptable and accessible to providers.     

Drug-usage evaluation in the community hospital

All hospital pharmacists can contribute to their medical staff's responsibility in completing effective DUR. The means available and practice environment for each setting will dictate specific methods to successfully complete DUR. It is not always necessary to have the most advanced systems or automated technology to make an impact on a DUR program. Often a simple, common sense approach to DUR can produce surprisingly effective results.     

DUE Software Highlights Therapeutic Issues: Drug use evaluation systems concurrently review prescribing criteria and patient medication history to identify potential drug therapy problems.

Drug use evaluation (DUE) or drug use review (DUR) for the ambulatory care setting is creating many opportunities to improve the pharmaceutical care provided by pharmacists. This study documents one year of peer-review interventions based on a retrospective drug utilization review software system (Qualisure, Q-A, Inc.) that screens patient profiles for a high likelihood of drug therapy problems. Letters are written to physicians and pharmacists providing care to these patients. The software identifles frequent opportunities for selecting therapeutic class alternatives to prescribed agents. Antibiotics, antihistamines, nonsteroidal anti-inflammatory drugs, and antidepressants were the classes for which therapeutic class alternatives were most often recommended.     

Drug costs and bacterial susceptibility after implementing a single-fluoroquinolone use policy at a university hospital

The University of Kentucky Hospital investigated the feasibility of choosing a sole fluoroquinolone for its formulary in an effort to reduce costs without affecting clinical outcomes. A three-step process was used to plan, implement, and monitor the selection program. Based on the range of clinical indications, safety profile, local susceptibility, cost, and dosing convenience, levofloxacin was chosen over ciprofloxacin and gatifloxacin as the sole fluoroquinolone. Since the implementation of the program in May 2001, susceptibility to levofloxacin has been maintained or increased for the most common pathogens. In addition, University Hospital has saved nearly 100,000 dollars in antibiotic acquisition costs during the first 12 months after the switch. This assessment did not take into account effects in clinical outcomes, such as clinical failures (such as readmission rates), mortality, and adverse events, or measure changes in overall medical expenditures beyond drug acquisition costs. In the future, monitoring of overall patient care and medical care costs, in addition to susceptibility patterns and drug costs, will allow for a better understanding of the long-term benefits of this switch.     

Design and Results of a Group Counter-detailing DUR Educational Program

Purpose. The study objectives were to (1) design, (2) implement and (3) evaluate a multi-step educational program as an integral component of a Healthcare system's activities to improve medication use quality and control drug costs. Design and implementation of the educational program were based upon established principles of changing prescriber behavior. Two classes of oral medications, antihistamines and antibiotics, were targeted. Methods. A before-after nonequivalent comparison group design with 2 comparison groups was used for evaluation. Medication claims data from the same time period one year previously were used as historical controls. Prescribing rates, net savings and preservers' attitudes were assessed. Results. Prescribing trends in the treatment group but not comparison groups generally reflected changes consistent with the educational message. A net savings of $84 was achieved in the antihistamine program. A net loss of ($2722) was seen in the antibiotic program. Over 75 percent of prescribers agreed or strongly agreed that the educational program was an appropriate mechanism to optimize medication use. Level of exposure and practice years affected perceived knowledge gains. Conclusions. The group counter-detailing DUR educational program was effective in improving prescribing rates. Prescribing rate changes and economic impacts differed by therapeutic category. The entire program was well accepted among prescribers including physicians and nurse practitioners.     

Economics of using pharmacists as advisers to physicians in risk-sharing contracts.

An educational program designed to help physicians control the overall cost of drugs and total health care is described, along with its effectiveness at one managed health care plan. Prime Therapeutics, Inc., developed and manages an ongoing physician education program designed to help primary care physicians control drug and total health care costs. Physician education initiatives in the program are developed by using peer-reviewed literature; selections of preferred drugs are based on evidence of their safety, efficacy, uniqueness, and cost-effectiveness. For a typical educational initiative, a pharmacist meets with the physicians identified as being among the top 20% of prescribers of high-cost drugs addressed by the initiative and delivers a 20-minute presentation. One-on-one meetings with the physicians are then held quarterly to review their prescribing. Each physician is shown comparisons with the prescribing patterns of other physicians in the organization. The clinic chooses to present the clinicwide data as either blinded or nonblinded data. The program was evaluated by comparing per member per month (PMPM) total health care and drug costs for 1996 and 1997 at 12 general medicine clinics in a managed health care plan. Five clinics received no interventions, three clinics allowed the initial presentation and the quarterly face-to-face meetings, and four clinics allowed only the presentation and barred ongoing meetings. In general, the clinics with more interaction between pharmacists and physicians had lower PMPM costs for total health care and drugs than the clinics with less interaction. Pharmacists acting as advisers to primary care physicians in general medicine clinics helped lower PMPM costs for drugs and total health care.     

On-Line OUR Messages: Pharmacists' Attitudes and Actions in Response: Of the DUR messages studied,pharmacists found Drug-Drug Interactions most useful.

Community pharmacists are encountering on-line drug utilization review (DUR) messages with increasing frequency. DUR messages are sent by third party claims processors and generated by pharmacies' inhouse computer systems. The purpose of this study was to ascertain community pharmacists' attitudes toward on-line DUR messages and the actions most often taken by pharmacists after receiving these messages. A 28-item questionnaire was mailed to a random sample of 1,500 community pharmacies throughout the United States. Four hundred twenty-seven questionnaires were returned and analyzed (a 28.5% response rate). The majority of respondents were male pharmacists practicing in independent community pharmacies in cities with populations of less than 50,000. The low response rate from chain pharmacies was an important limitation of this study. The results indicate that pharmacists find DUR messages related to medication overuse and drug interactions to be the most useful. Interventions are not performed for all DUR messages received, and interventions usually consist of telephoning physicians and talking to patients. This study demonstrates that many types of DUR messages are useful to pharmacists; however, additional research and further refinement of DUR messages appear necessary.