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PubMed2006

Anti-hypertensive drug utilization in Continental Portugal (1999-2004).

INTRODUCTION: The estimated prevalence of arterial hypertension (HT) in Portugal in 2003 was 43%, with only 28.8% of patients undergoing antihypertensive treatment having their blood pressure controlled. In the light of this fact, if HT is detected early and adequately controlled, there is great potential for reducing cardiovascular morbidity and mortality. OBJECTIVES: This study aimed to analyze patterns of antihypertensive drug utilization in Portugal at the regional and national level, to compare them with other countries, and to evaluate trends in certain indicators regarding use of these drugs. METHODS: Data on antihypertensive drug utilization refer to drugs prescribed and dispensed in the ambulatory population covered by the Portuguese national health service, from January 1, 1999 to June 30, 2004. Data were expressed in defined daily doses (DDD) per 1000 inhabitants per day (DID). RESULTS: Use of antihypertensives increased from 183 DID in the first half of 1999 to 256 DID in the first half of 2004, an increase of 40%. Angiotensin-converting enzyme inhibitors were the most frequently prescribed drug class, being used by 31% of the study population, followed by diuretics (16%) and calcium channel blockers (14%). Angiotensin receptor blockers (ARBs) accounted for most of the growth in antihypertensive use, although they represent the most expensive therapeutic option. This pattern of use had a strong impact on antihypertensive drug expenditure, which increased 60% over the study period. ARBs, plain or in combination formulations, accounted for 55% and 71% of the increase in utilization and expenditure respectively. DISCUSSION: From the standpoint of health gains, the significant rise in antihypertensive drug utilization represents a potentially favorable development in terms of increased numbers of patients undergoing drug treatment. Compared to other European countries, the data showed greater use of drugs that act on the renin-angiotensin system in Portugal and less use of diuretics and beta-blockers. Most national and international guidelines recommend diuretics as first-line agents in HT treatment. Considering that these drugs have the lowest daily treatment cost, a high, and increasing, rate of utilization would be expected, but this is not the case in Portugal. CONCLUSIONS: This study reveals not only significant differences in antihypertensive drug utilization at the regional level in Portugal but also a lack of adherence to national and international guidelines, and therefore more attention should be paid to their implementation in order to improve health gains.

Antihypertensive Agents↗
PubMed1999

A survey of the treatment of female patients with osteoporosis using drug utilization consumption parameters.

OBJECTIVE: To investigate the drug treatment of female patients who were diagnosed with osteoporosis in South Africa using drug utilization consumption parameters. METHOD: Prescription data over a 2-year period for 1655 female patients with osteoporosis were analysed retrospectively. RESULTS: A total of 157,245 products at a cost of R15,004,643.51 was prescribed. Two-thirds of the patients fell in the age group between 50 and 69 years. A quarter (25.33%) of the products prescribed were identified as products specifically for the treatment and/or prevention of osteoporosis. Calcium supplements were the most frequently prescribed therapeutic subgroup, followed by hormone replacement therapy. The most frequently prescribed product was an effervescent calcium supplement containing 500 mg elemental calcium. Alendronate 10 mg tablets accounted for the highest cost (23.57% of the total cost of products for osteoporosis), but accounted for only 7.36% of the number of products prescribed for osteoporosis. Prescribing differences were observed for patients younger than 50 years, and patients 50 years and older. The DU90% and DC90% segments consisted of 27 and 24 different trade name products, respectively. CONCLUSION: Further studies focusing on the cost of osteoporosis treatment and prevention should be conducted incorporating clinical information.

Aged↗
PubMed2004

Psychotropic drug utilization in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

OBJECTIVE: To assess psychotropic drug utilization in the general population of six European countries, and the pattern of use in individuals with different DSM-IV diagnoses of 12-month mental disorders. METHOD: Data were derived from the European Study of the Epidemiology of Mental Disorders (ESEMeD/MHEDEA 2000), a cross-sectional psychiatric epidemiological study in a representative sample of 21 425 adults aged 18 or older from six European countries (e.g. Belgium, France, Germany, Italy, the Netherlands and Spain). Individuals were asked about any psychotropic drug use in the past 12 months, even if they used the drug(s) just once. A colour booklet containing high-quality pictures of psychotropic drugs commonly used to treat mental disorders was provided to help respondents recall drug use. RESULTS: Psychotropic drug utilization is generally low in individuals with any 12-month mental disorder (32.6%). The extent of psychotropic drug utilization varied according to the specific DSM-IV diagnosis. Among individuals with a 12-month diagnosis of pure major depression, only 21.2% had received any antidepressants within the same period; the exclusive use of antidepressants was even lower (4.6%), while more individuals took only anxiolytics (18.4%). CONCLUSION: These data question the appropriateness of current pharmacological treatments, particularly for major depression, in which under-treatment is coupled with the high use of non-specific medications, such as anxiolytics.

Adolescent↗
PubMed1984

Drug utilization and morbidity statistics for the evaluation of drug safety in Sweden.

For a continuous monitoring and evaluation of drug safety problems in Sweden, the Department of Drugs of the National Board of Health and Welfare has access to a number of computerised patient-, drug-, and disease-oriented registers. The usefulness and limitations of these registers are presented by examples. A recent increase in asthma deaths is presently being analysed by comparing information from death certificates and case records with drug sales and prescription data. A recent analysis of the cancer register showed no increased risk of malignant thyroid tumors after diagnostic or therapeutic doses of I 131. Similarly no increased risk of malformations after occupational exposure to hexachlorophene could be detected by analysing the malformation and medical birth-record registers in relation to hospital hexachlorophene use. The register of patient discharge diagnoses has been repeatedly used to analyse the incidence and pattern of drug induced blood dyscrasias and thromboembolism associated with oral contraceptives (OC). These analyses have resulted i.a. in the withdrawal of dipyrone and tenalidine and a decrease of the estrogen-content of OCs. At the same time about 1/3 of these serious adverse drug reactions (ADR) was found to have been reported to the ADR-register. By combining sales and prescription data with ADR-reports the risk of inducing lactic acidosis was found to be significantly higher for phenformin than for metformin. Also the incidence of tardive dyskinesia from longterm use of metoclopramide was found to be much higher than hitherto recognized. By use of these registers it is possible to obtain valuable information about the safety of drugs. The raw data must, however, be interpreted with care and often be supplemented with in depth studies of the various problems.

Acidosis↗
PubMed1996

Variability in prescription drug utilization: issues for research.

The authors report the results of a literature review to identify research issues relating to physician prescribing practices and evaluate the potential for existing Canadian databases to support initiatives to improve prescribing practices. Methodologies such as small-area variation analysis and drug utilization reviews are discussed, and Canadian data sources relating to drug prescribing are assessed. The authors conclude that small-area variation analysis can be used to identify differences in drug utilization rates. A ranking method to identify drugs with the greatest variability in utilization can then be used to establish priorities for further analysis. After statistically significant factors associated with prescribing patterns are identified, intervention and policy formation will be possible. This will involve a more sophisticated integration of existing provincial information sources and the adoption of uniform guidelines to promote rational prescribing practices.

Aged↗
PubMed1995

Drug utilization review in the managed care environment.

Traditional drug use evaluation (DUE) and Medicaid drug utilization review (DUR) prototypes do not meet the needs of managed care organizations. yet, creating entirely new systems for measuring quality drug use in managed care, such as HEDIS, needlessly discards the good clinical foundations already built in the other health care settings. A better solution would be for managed care to apply its hallmark traits, namely state-of-the-art electronic data management systems, integrated health care system interchange, and strong customer communication, to make the DUR process better. A strong union between clinical criteria and sophisticated health care management can revolutionize the DUR/DUE process.

Consumer Behavior↗
PubMed2003

The ineffectiveness of retrospective drug utilization review.

As policymakers debate adding a prescription drug benefit to Medicare, they must also seek ways to promote cost-effective use of drugs and minimize inappropriate prescribing. For more than a decade, all state Medicaid agencies and most private insurers have used computerized drug utilization review (DUR) programs to prevent or rectify potential prescribing errors. DUR can be retrospective, in which claims data are reviewed to identify patterns of drug use, or prospective, in which prescriptions are reviewed before a drug is dispensed. This Issue Brief summarizes a landmark study that suggests that retrospective DUR has had no measurable effects on outpatient drug use or clinical outcomes in the Medicaid program.

Drug Utilization Review↗
PubMed2003

Dosage finding and outcome of venlafaxine treatment in psychiatric outpatients and inpatients: results of a drug utilization observation study.

BACKGROUND: Venlafaxine is an antidepressive drug with the special characteristic of inhibiting both synaptic serotonin and norepinephrine reuptake. This double action is dosage dependent, with the relatively weaker inhibition of norepinephrine becoming clinically relevant only at higher dosages. This allows treatment to be tailored towards the needs of individual patients through differential dosing. It is unknown, however, how physicians use this unique feature in prescribing venlafaxine in routine treatment. METHOD: Data from a drug utilization observation (DUO) study, including 6706 patients, are used to investigate which patient and setting variables predict dosage of venlafaxine as prescribed by psychiatrists in inpatient and outpatient settings. Treatment outcome and adverse drug reactions (ADR) were analyzed for different dosage groups. RESULTS: Treatment setting is the most important factor in predicting high (> 75 mg/day) or low (up to 75 mg/day) dosage of venlafaxine, with inpatients receiving higher dosages. Severity of illness and a history of previous treatment with major antidepressives are also related to higher dosages. Although the total rate of ADR did not increase with increased dosage, the profile of drug reactions changed. Response to therapy was better in cases of non-chronic, major depression with no treatment history of antidepressives. Additionally, increased dosage increased the likelihood of response in outpatients. In both settings, very high dosages predicted better response to venlafaxine among severely ill patients. CONCLUSION: Venlafaxine at a dosage of 75 mg/day is sufficient for the majority of cases. In extremely ill patients, higher dosages are associated with additional benefits. Therefore, a stepwise dosage regimen is suggested, with an increase of dosage to upper limits in cases of non-response before discontinuation of treatment with venlafaxine.

Adolescent↗
PubMed2006

Drug utilization review on a tertiary palliative care unit.

Drugs are indispensable for the management of symptoms in palliative care patients, and account for a significant proportion of expenditures on a Tertiary Palliative Care Unit (TPCU). Drug expenditures for Edmonton's TPCU increased by 40% in 2002 compared to 2001. Fifty-five percent of the increase was attributable to injectable fentanyl, oral and injectable ondansetron, and total parenteral nutrition (TPN). As there was no increase in the unit cost of these drugs between 2001 and 2002, the increased expenditures reflected increased utilization. The hypothesis of this study was that the increased utilization of these drugs reflected appropriate prescribing. The objective was to compare the indications for prescribing these drugs in 2002 against evidence- and consensus-based criteria. Patients who received these drugs while admitted to the TPCU from January 1 to December 31, 2002 were identified through the pharmacy database. Evidence- and consensus-based criteria for drug utilization were developed. Prescribing indications were retrospectively compared against the criteria. Drug prescriptions were categorized as follows: (1) meeting criteria, (2) not meeting criteria, or (3) uncertain. The drugs under study were prescribed during 48 out of 234 admissions to the TPCU in 2002. Prescriptions for fentanyl met criteria in 26 of 29 cases. Indications were unsuccessful therapy with morphine, hydromorphone, and oxycodone (20), requirement for rapid titration from fentanyl patch (5), renal failure (2), and sublingual administration for breakthrough pain (1). Prescriptions for ondansetron met criteria in 19 of 21 cases. Indications were nausea refractory to metoclopramide and dexamethasone (13), and nausea related to radiotherapy or chemotherapy (6). Prescriptions for TPN met criteria for initiation in only one of five cases. However, in all cases, TPN had been started prior to admission. In cases where death was considered imminent, TPN was continued pending consultation with the patient and family regarding discontinuation. These data indicate that the increased prescribing of fentanyl and ondansetron on the TPCU satisfied evidence- and consensus-based criteria in most cases, apparently justifying the associated increase in drug expenditures. This type of analysis may be useful whenever increased drug utilization requires review. A cost effectiveness analysis would be the next step in evaluating the costs vs. the benefits. The issue of discontinuing TPN in palliative care patients requires further investigation.

Adult↗
PubMed1999

Drug utilization reviews of oral quinolone, cephalosporin, and macrolide use in nonacute care: a systematic review.

Drug utilization review (DUR) is a tool for monitoring the appropriateness of physicians' prescribing patterns. The present systematic overview was undertaken to determine the extent of appropriate use of oral quinolones, cephalosporins, and macrolides in nonacute-care settings in North America reported in published DUR studies. Potentially relevant DURs conducted since 1987 were retrieved from an electronic search of 6 databases (augmented by manual searches of bibliographies of appropriate articles) and from personal communications with local experts. Independent reviewers applied objective criteria to select the DURs for inclusion. Quality assessments were performed by 4 independent reviewers using the Edmonton Quality Assessment Tool for Drug Utilization Reviews, an instrument developed to assess the potential for systematic bias in a DUR. Data from the studies included were abstracted independently by 2 reviewers using a standard data-collection form. Twelve of 587 (2.0%) articles met the inclusion criteria. Eight studies targeted the appropriateness of prescriptions for ciprofloxacin (appropriateness range, 5% to 95%), 3 included cephalosporins (range, 0% to 100%), and 2 examined erythromycin (40%). There were 2 primary reasons for a rating of inappropriate: (1) the prescription was not first-line therapy, or (2) there was insufficient documentation in the patient record. The designation inappropriate did not mean that the drug did not benefit the patient. Of the 4 intervention-based DURs, 1 study showed a significant improvement in appropriate use. Because of heterogeneity in study design, delivery of interventions, and outcome assessment, a pooled estimate of effect was not derived. Four studies estimated the cost of inappropriate prescribing to the institutional study site, which ranged from $20,500 to $173,359 annually; however, these estimates cannot be generalized because of various limitations. When the 12 studies were assessed for methodologic quality, 1 study was rated as high, 7 as moderate, and 4 as low. Levels of prescribing appropriateness reported in the DUR literature should be interpreted cautiously. The DUR studies included in this review varied greatly in the methodologic rigor applied to sample selection, standardized data collection, application of standardized screening criteria, and validated data analysis.

Bacterial Infections↗
PubMed2006

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.

Bibliometrics↗
PubMed1995

Acute myocardial infarction treatments in 58 Italian hospitals: a drug utilization survey.

OBJECTIVES: To provide an updated and comprehensive profile of therapeutic practice in the management of acute myocardial infarction (AMI) in a sample of Italian hospitals, and to test the possible role of a network of hospital pharmacists in providing drug utilization data. DESIGN: Prospective drug utilization survey. Participating pharmacists collected information on patients consecutively admitted to the hospital with a suspected AMI. The form reproduced those adopted in the Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico trials. SETTING: Fifty-eight general hospitals in Italy belonging to the National Health Service, 6 of which are teaching hospitals. Thirty-four hospitals recruited patients from a coronary care unit, 10 from intensive monitoring beds in cardiology wards, and 14 from an intensive care unit. PARTICIPANTS: The study population consisted of patients consecutively admitted with a suspected AMI from May 31 through July 5, 1993. MAIN OUTCOME MEASURES: The management of AMI in terms of the use of drugs and nonpharmacologic treatments is described. RESULTS: Of the 676 patients recruited for the study, 47.8% received thrombolytic therapy; alteplase was the preferred agent (55.4% of treated patients). The use of thrombolytic therapy varied significantly according to different demographic and clinical parameters such as age, sex, delay from the onset of symptoms to admission, and Killip scale class. During the first day of hospitalization 63.9% of patients received aspirin, 83.3% received nitrates, 24.8% received beta-blockers, and 77.1% received heparin therapy. CONCLUSIONS: Thrombolytic therapy was prescribed in a higher percentage of patients than is reported in the US, but lower than that reported in large trials. That a low percentage of patients who experienced a long delay between the onset of symptoms and admission as well as elderly patients received thrombolytic therapy reflects the lower expectations of clinicians for these subgroups of patients. A low proportion of patients received aspirin therapy. This study showed that in Italy an institutional network of hospital pharmacists could be interested observers of therapeutic practice, but further training is needed before high-quality data can be collected.

Adrenergic beta-Antagonists↗
PubMed2005

Drug utilization statistics for individual-level pharmacy dispensing data.

The emergence of large, computerized pharmacoepidemiologic databases has enabled us to study drug utilization with the individual user as the unit of analysis. A recurrent problem in such analyses, however, is the overwhelming volume and complexity of data. This paper reviews the methods to estimate basic epidemiologic measures of drug utilization and some methods to screen for aberrant prescribing patterns. It also presents the basis and application of the waiting time distributions that can provide information about the period prevalence, point prevalence, incidence, duration of use, seasonality and rate of prescription renewal or relapse for specific drugs. If analyzed regularly, these measures can disclose subtle trends in clinical drug use that would not be evident from the wholesale figures. In specific situations, pharmacy dispensing data without diagnostic information can be used to assess the association between drug use and adverse effects in a prescription symmetry design.

Age Factors↗
PubMedDate not supplied

Effects of Medicaid drug utilization review intervention letters.

The state of Texas Drug Utilization Review (DUR) Board, composed of six physicians and six pharmacists, meets quarterly to determine criteria for implementing retrospective DUR. The board agreed to send intervention letters to physicians concurrently prescribing: (1) two histamine2 (H2)-antagonists (H2As) or (2) either any H2A or omeprazole with sucralfate. To measure the effect of these intervention letters, approximately half of these physicians were randomly chosen to receive a letter while the others served as a control group and did not receive letters. This project focused on the H2A or omeprazole with sucralfate intervention letters in a two-step process. Data on concurrent therapy involving two H2As were analyzed separately and these results are not included in this report. Objective one was to examine feedback from the physicians who received the letters, and objective two was to review and compare patient profiles 6 months after the letters were sent. Analysis of Medicaid prescription claims indicated that 190 physicians had concurrently prescribed either an H2A or omeprazole with sucralfate for 222 patients. Ninety-seven physicians (from 117 identified patient profiles) were selected to receive an intervention letter with their patient's profile or profiles, a response form, and a stamped envelope addressed to the Texas Department of Human Services. A 67.5% response rate was obtained. Of these responses, 49.4% agreed with the letter and 29.1% disagreed with the letter. The remaining indicated responses such as "not my patient," they were no longer seeing the patient, or that they did not prescribe the medication in question. (ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1986

Therapeutic traditions in Northern Ireland, Norway and Sweden: II. Hypertension. WHO Drug Utilization Research Group (DURG).

A questionnaire survey based on hypertension case histories was performed among a representative sample of 400 GP's and hospital doctors in Northern Ireland, Norway and Sweden, countries having markedly different utilization of antihypertensive drugs. We found a greater propensity to start antihypertensive drug treatment in Northern Ireland than in Norway and Sweden. This was true both in mild diastolic and isolated systolic hypertension. Yet the utilization of antihypertensive drugs in Sweden is about 60% higher than in Northern Ireland and 30% higher than in Norway. Swedish physicians preferred beta-blockers as their first choice to a greater extent than physicians in Northern Ireland and Norway who selected thiazides more often. In general, the choice of drugs agreed with the sales and prescribing patterns in the three countries. Besides providing more insight in therapeutic traditions the study indicates that the lower prescribing of antihypertensive drugs in Northern Ireland, and to some extent in Norway, compared to Sweden, might be due to differences in true or apparent morbidity.

Antihypertensive Agents↗
PubMed2005

Mental health-related drug utilization among older adults: prevalence, trends, and costs.

OBJECTIVE: Authors assessed temporal changes in mental health-related drug utilization and costs in an older population. METHODS: This was a population-based, cross-sectional time-series analysis of more than 1.4 million residents of Ontario, Canada, age 65 years or older. The study examined mental health-related drug utilization and costs, as derived from administrative databases from 1993 through 2002. They assessed use of antidepressants, antipsychotics, mood stabilizers, benzodiazepines, and acetylcholinesterase inhibitors (AChEIs), assessing trends over time. RESULTS: The prevalence of mental health-related drug use increased from 21.3% of the older population in the beginning of 1993 to 23.8% by the end of 2002. The proportion of benzodiazepine prescriptions was the highest of all such drugs, but declined from approximately 67% of prescriptions, in 1993, to 38%, in 2002. Significant temporal increases were observed for use of antidepressants (5.6%, in 1993, to 10.9%, in 2002), antipsychotics (1.9% in 1993; 2.9% in 2002), and AChEIs (0.1% in 1999; 1.5% in 2002). These increases were associated with a 210% increase in total standardized expenditures on mental health-related drugs, from approximately $32 per older resident ($40 million total) in 1993 to $99 per older resident ($149 million total) in 2002. AChEIs accounted for fewer than 6% of prescriptions, but 25% of the costs. CONCLUSIONS: Significant shifts in prescription of mental health-related drugs and their costs have occurred over the past decade among older individuals with the introduction of newer, more expensive agents. Future research should address the appropriate balancing of increased costs versus their benefits in this population.

Aged↗
PubMedDate not supplied

Intensive care unit drug utilization in a teaching hospital in Nepal.

OBJECTIVES: The intensive care unit (ICU) is a setting where a large number of drugs are administered to patients and the costs of hospitalization and drug treatment are high. Information on drug utilization in intensive care units (ICUs) are lacking in western Nepal. The present study was carried out to obtain information on the basic demographic pattern of the respondents, drug utilization during the study period, the antibiotic sensitivity patterns of isolated microorganisms and measure drug consumption in defined daily dose (DDD)/ 100 bed-days. METHODS: A retrospective analysis of patients admitted to the ICU of the Manipal Teaching hospital, Pokhara, Nepal during the time period from 01/02/2002 to 31/05/2002 was carried out. The ICU mortality rate, length of stay greater than 7 days and median length of stay were calculated. RESULTS: A total of 259 individuals were admitted. The ICU mortality rate was 15.4%; median length of stay was 4 days. E.coli, H.influenzae, K.pneumoniae, S.aureus and P.aeruginosa were the common organisms isolated and were found to be resistant to some of the commonly used antibiotics. Mean +/- SD number of drugs and cost of drugs were 5.1 +/- 2.7 and 1958.5 +/- 1267.8 Nepalese rupees (25.1 +/- 16.2 US dollars). Total drug consumption was 356.4 DDD/100 bed-days. Consumption of intravenous fluids was 25.8 litres/100 bed-days. CONCLUSIONS: An antibiotic use policy should be framed. Formation of a multidisciplinary team to oversee drug use and periodically review microbial sensitivity patterns will be helpful. Longitudinal surveillance of ICU drug use should be carried out.

Anti-Bacterial Agents↗
PubMed1977

Watching the monitors: "PAID" prescriptions, fiscal intermediaries and drug-utilization review.

Prescription monitoring evolved from the need of drug firms to obtain marketing information. Today, extensive monitoring is also done by fiscal intermediaries who administer prepaid drug benefit plans, both private and governmental, particularly Medicaid. The most important such agent is PAID Prescriptions. Under various contracts, PAID monitors physician, pharmacy, and patient behavior related to prescriptions and uses review processes that evaluate certain kinds of behavior for appropriateness. The criteria of appropriateness are essentially those that save money. PAID negotiates a program fee with the insurer (public or private) and applies constraints so that prescription and administrative costs do not overrun that fee. PAID and other monitors have contemplated expansion into the realm of defining and encouraging appropriate prescribing under the concept of "drugutilization review." The actual practices of PAID, particularly the background of fiscal enforcement, may impede the development of an actual drug-utilization review process.

Blue Cross Blue Shield Insurance Plans↗