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PubMed2007

Utilization review of concomitant use of potentially interacting drugs in Thai patients using warfarin therapy.

PURPOSE: In Thailand, there has been no study determining the concomitant use of medications, known to potentially interact with warfarin, in patients receiving warfarin therapy. This paper examined the frequency of which specific interacting drugs were concomitantly used in warfarin users. METHODS: We retrospectively examined the database of warfarin outpatient medical records from a regional 756-bed hospital located in the north of Thailand. All patients receiving warfarin from 10 June 1999 to 4 August 2004 were reviewed to identify all drugs possessing interaction potential with warfarin. The potential of significant interactions were divided into high, moderate and low, according to the extent of evidence documented in textbooks and literature. RESULTS: Among 1093 patients receiving warfarin therapy, 914 (84%) patients received at least one potentially interacting drug and half of them (457 patients) received at least one drug with high potential for interaction. The most frequently concomitant drug that increased INR was acetaminophen (63%, 316/457). Propylthiouracil was the most frequently concomitant drug that decreased INR response (4%, 19/457), while diclofenac was the most frequently concomitant drug that increased bleeding risk (16%, 73/457). CONCLUSIONS: About a half of patients receiving warfarin therapy was prescribed concomitant drug(s) that has a high potential of interactions with warfarin. These patients should be closely monitored and counselled to watch for signs and symptoms of bleeding and thrombosis to avoid adverse events associated with drug interactions.

Acetaminophen↗
PubMed1993

Ensuring excellence: reconceptualizing quality assurance, risk management, and utilization review.

A new conceptualization of the related activities QA, RM, and UR may allow an organization to ensure appropriate, proficient, and satisfactory care and to ameliorate the consequences of bad outcomes. Three processes incorporated into the conceptualization are essential to ensuring excellence, as are specific attributes of the care process. The difference in initiation of activities (reactive versus proactive) is part of the model; relationships among the essential activities and processes and between reactive and proactive activities are suggested; and viewing data sources or collection as separate from the processes and activities is suggested. Areas for development and research within the conceptualization that are inadequately understood include data sources and analysis methods useful for the processes needed, evaluation of the consequences of different reactive activities, and the usefulness of TQI activities for setting goals or standards and for changing behavior. Implementing such an approach to ensuring excellence would be a challenge. It is hoped that this formulation will assist in communication among those working to ensure excellence; promote analysis of whether current organizational structures for ensuring excellence and for cost containment are creating redundance, competition, or gaps in needed activities; broaden the perception of the possible and/or appropriate scope of some activities, such as the inclusion of proactive preventive care and the provision of special high-risk programs; and assist in the identification of areas of needed research and development.

Health Services Research↗
PubMed1992

The Nebraska Medicaid Drug Utilization Review Program.

There are reports in the literature which address the effects of DUR on morbidity and cost containment in a non-acute setting. Most of the information, however, is under acute care circumstances. Some of the studies performed under these situations have shown added benefits in terms of patient care. This article attempts to document similar changes in morbidity and cost containment in a relatively ambulatory Medicaid population. It must be remembered that the Medicaid population in Nebraska is composed of some patients who are institutionalized in a variety of settings. In 1989, the Medicaid population had an average age close to 65. Forty-three percent of these patients resided in a nursing home and may have either received hospitalization as a result of a Drug Therapy Problem or incurred added expenses while maintaining residency in a long-term care environment. The cost savings noted here do not reflect other factors such as the effects of age, race, gender, residential status, diet, smoking, exercise, disease prior to Medicaid enrollment, etc. This estimate does not take into account the effects of increased ingredient or administrative costs. Any increases in claims amount over time would tend to boost cost savings while increases in administrative expenses would tend to blunt this effect. If an adjustment was made for age, gender and other factors, cost-savings could be affected. Additionally, the DUR program does not include any drug effects which could be attributable to changes in other prescribed medications secondary to the original inquiry.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost Control↗
PubMed1998

Treatment of Medicaid patients with asthma: comparison with treatment guidelines using disease-based drug utilization review methodology.

OBJECTIVE: To compare asthma drug therapy in the Iowa Medicaid population with international treatment guideline recommendations and relate differences to patient outcomes. METHODS: Data on asthma drug therapy and respiratory-related medical services (clinic visits, emergency visits, hospital admissions) were abstracted from prescription claims and diagnostic codes of adult Iowa Medicaid patients with asthma (n = 1029). RESULTS: About two-thirds of the population received a prescription for a short-acting beta 2-agonist during the study period. Patients with greater daily use of short-acting beta 2-agonists had more clinic visits (p = 0.004), likely related to illness severity. Almost one-third (29.3%) of 58 patients receiving a prescription of salmeterol did not receive the recommended prescription of a short-acting beta 2-agonist inhaler in the 6-month period. About one-half of patients who should have been prescribed inhaled corticosteroids according to the international guidelines did not receive such a prescription in the 6-month study period. Increased use of inhaled corticosteroids was associated with fewer (p = 0.04) emergency visits. CONCLUSIONS: Suboptimal asthma treatment in the Iowa Medicaid population, especially in regard to the use of inhaled corticosteroids as preventive therapy, was evident after comparison with treatment guidelines. Increased daily use of inhaled corticosteroids was associated with positive patient outcomes in accordance with guideline recommendations. Educational efforts to improve closer adherence to international guidelines both in prescribing practices and patient compliance with medication for asthma management should be undertaken.

Administration, Inhalation↗
PubMed1994

Drug utilization review on a surgical intensive care unit.

Drug use reviews (DUR) provide information about drug prescription patterns. At the surgical intensive care unit (SICU) of the University Hospital Frankfurt/Main we recorded the indication related administration of blood products and pharmaceuticals (which were responsible for 60% of the total costs at the SICU in the year before) over a 4-month investigation period. Data were recorded and analyzed using a notebook-PC. 207 Patients were included, and recorded total expenditures came to $551,592. The 10 leading substances, represented by antibiotics and blood-products, caused more than 70% of total costs. The usage of these high-cost substances and the most expensive complications are identified and discussed. We concluded that DURs are useful for obtaining information about drug usage patterns and for identifying high cost drugs, which are of economic interest. Furthermore, the indications for the application of these substances can be identified. Our results suggest, that blood and blood-products should always be included in DURs. In our opinion, especially the usage of blood-products represents a field where considerable cost savings may be expected. As certain complications during the postoperative course (e.g. sepsis) may increase costs, they should be considered in the reimbursement negotiations between hospitals and health insurance.

Adult↗
PubMed2003

Drug utilization review of celecoxib in Ontario.

Cyclooxygenase (COX)-2-specific inhibitors were developed to circumvent the gastrointestinal toxicity of non-specific non-steroidal anti-inflammatory drugs while maintaining efficacy. However, the higher acquisition cost of COX-2-specific inhibitors has resulted in the implementation of a programme for cost containment in the Ontario public drug program. This programme consists of limited use (LU) criteria that need to be met for drug reimbursement of patients with osteoarthritis (OA) or rheumatoid arthritis (RA). Determining the proportion of patients eligible for reimbursement for celecoxib according to the LU criteria (based on prior treatment failure and the presence or history of serious ulcer-related gastrointestinal complications) can provide an indication of the extent of adherence to suggested guidelines. Using a patient-based survey and an analysis of the Ontario Drug Benefit Program database, the proportion of patients prescribed celecoxib who met rigorous or pragmatic definitions of the LU criteria was determined. The extent of coprescription of gastroprotective agents among patients taking celecoxib was also determined. Using the pragmatic definition, the majority of patients in the patient-based survey (53% for OA and 81% for RA) met the LU criteria. Similarly, in the database analysis, the majority of patients (76% for OA and 78% for RA) met the LU criteria. These data suggest that physician prescribing of celecoxib is consistent with the LU criteria. Concomitant prescription of gastroprotective agents in patients taking celecoxib was approximately 40%. It is recommended that further investigations be performed to determine the long-term impact of LU criteria on clinical and economic outcomes, since these criteria may also serve to restrict use in patients who may benefit from taking COX-2-specific inhibitors.

Aged↗
PubMed2000

How is mechanical ventilation employed in the intensive care unit? An international utilization review.

A 1-d point-prevalence study was performed with the aim of describing the characteristics of conventional mechanical ventilation in intensive care units ICUs from North America, South America, Spain, and Portugal. The study involved 412 medical-surgical ICUs and 1,638 patients receiving mechanical ventilation at the moment of the study. The main outcome measures were characterization of the indications for initiation of mechanical ventilation, the artificial airways used to deliver mechanical ventilation, the ventilator modes and settings, and the methods of weaning. The median age of the study patients was 61 yr, and the median duration of mechanical ventilation at the time of the study was 7 d. Common indications for the initiation of mechanical ventilation included acute respiratory failure (66%), acute exacerbation of chronic obstructive pulmonary disease (13%), coma (10%), and neuromuscular disorders (10%). Mechanical ventilation was delivered via an endotracheal tube in 75% of patients, a tracheostomy in 24%, and a facial mask in 1%. Ventilator modes consisted of assist/control ventilation in 47% of patients and 46% were ventilated with synchronized intermittent mandatory ventilation, pressure support, or the combination of both. The median tidal volume setting was 9 ml/kg in patients receiving assist/control and the median setting of pressure support was 18 cm H(2)O. Positive end-expiratory pressure was not employed in 31% of patients. Method of weaning varied considerably from country to country, and even within a country several methods were in use. We conclude that the primary indications for mechanical ventilation and the ventilator settings were remarkably similar across countries, but the selection of modes of mechanical ventilation and methods of weaning varied considerably from country to country.

Data Collection↗
PubMed2000

Noninvasive positive-pressure ventilation: a utilization review of use in a teaching hospital.

BACKGROUND: The use of noninvasive positive-pressure ventilation (NIPPV) for acute respiratory failure (ARF) has become more widespread over the past decade, but its prescription, use and outcomes in the clinical setting remain uncertain. The objective of this study was to review the use of NIPPV for ARF with respect to clinical indications, physician ordering, monitoring strategies and patient outcomes. METHODS: A total of 91 consecutive adult patients admitted between June 1997 and September 1998 to a university-affiliated tertiary care hospital in Hamilton, Ont., who received 95 trials of NIPPV for ARF were included in an observational cohort study. Data abstraction forms were completed in duplicate, then relevant clinical, physiologic, prescribing, monitoring and outcome data were abstracted from the NIPPV registry and hospital records. RESULTS: The most common indications for NIPPV were pulmonary edema (42 of 95 trials [44.2%]) and exacerbation of chronic obstructive pulmonary disease (23 of 95 trials [24.2%]). NIPPV was started primarily in the emergency department (62.1% of trials), however, in terms of total hours of NIPPV the most frequent sites of administration were the intensive care unit (30.9% of total hours) and the clinical teaching unit (20.2% of total hours). NIPPV was stopped in 48.4% of patients because of improvement and in 25.6% because of deterioration necessitating endotracheal intubation. The median time to intubation was 3.0 hours (interquartile range 0.8-12.2 hours). The respirology service was consulted for 28.4% of the patients. Physician orders usually lacked details of NIPPV settings and monitoring methods. We found no significant predictors of the need for endotracheal intubation. The overall death rate was 28.6%. The only independent predictor of death was a decreased level of consciousness (odds ratio 2.9, 95% confidence interval 1.0-8.4). INTERPRETATION: NIPPV was used for ARF of diverse causes in many hospital settings and was started and managed by physicians with various levels of training and experience. The use of this technique outside the critical care setting may be optimized by a multidisciplinary educational practice guideline.

Adult↗
PubMed1982

The use of ancillary services: a role for utilization review?

Despite both the increasingly high cost of ancillary services such as laboratory tests, x-ray examinations and prescription drugs, and the authority provided to Professional Standards Review Organizations to review their use, ancillary services review remains underdeveloped. Several early programs have used claims review or profile analysis to assess the appropriate use of ancillary services and have claimed effectiveness in reducing medical care costs. Based on this experience, several principles for ancillary services review may be set forth, including problem identification, design of the audit system, determination of requirements for data and development of data sources. Evaluation of model ancillary service review programs is necessary to demonstrate their cost-benefit or cost-effectiveness and their validity.

Costs and Cost Analysis↗
PubMed2004

Drug utilization review of risperidone for outpatients in a tertiary referral hospital in Singapore.

BACKGROUND: Risperidone has been used in Singapore for schizophrenia since 1996. However, little information is available on its utilization pattern. OBJECTIVE: To examine the risperidone utilization pattern in the Psychiatric Outpatient Clinic of the National University Hospital. METHOD: Medical records of all outpatients with schizophrenia prescribed with risperidone from 1 September1999 to 31 August 2000 were reviewed. RESULTS: A total of 417 risperidone prescriptions were dispensed for 130 outpatients (50 male, 80 female) during the study period. The mean +/- SD daily doses for prescriptions and for patients were 2.3 +/- 1.3 mg and 2.1 +/- 1.1 mg, respectively. Among these patients, 28 (21.5%) received at least one concomitant conventional antipsychotic and 71 (54.6%) received a concomitant anti-Parkinsonian agent. Logistic regression analysis suggested that a higher risperidone dose was associated with the greater probability of anti-Parkinsonian agent usage. CONCLUSIONS: The mean risperidone dose during the study period was towards the lower end of recommendation for schizophrenia. Further study is warranted to confirm and explain the pattern of low-dose risperidone, and the high use of concomitant conventional antipsychotics and anti-Parkinsonian agents in Singapore. Elucidation of these would provide a valuable insight for the management of Asian patients with schizophrenia using risperidone. However, the current data indicate that the practice of using a lower dose of risperidone could represent better affordability and an improved cost-effectiveness ratio of risperidone compared with conventional antipsychotics in Asian patients.

Adolescent↗
PubMed1987

Multicyclic antidepressant serum drug assays: a utilization review.

Multicyclic antidepressant (MCA) kinetics are complex and influenced by many factors, making clinical interpretation of serum concentration data difficult. To assess the effectiveness of MCA serum assay utilization in a private, university-affiliated psychiatric hospital, actual use over a 1-year period was reviewed retrospectively against criteria derived from the contemporary literature. Overall, compliance with the criteria was poor. Documentation of reasons for ordering MCA assays and subsequent therapy decisions were also poor. As a result, guidelines for the appropriate use of this clinical tool have been accepted by the institution's P & T Committee and will be reinforced through a continuing medical education program.

Antidepressive Agents, Tricyclic↗