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PubMed1984

Identification of drug costs within diagnosis related groups.

This study was designed to identify the DRG distribution of discharged Medicare patients during a given period of time in two similar hospital sites. Additionally, drugs costs (both total and average) for each patient in these DRGs were determined and analyzed as to similarity between the two sites as well as significance in terms of percentage of DRG total reimbursement rate. The assumption that DRGs would be homogeneous for drug costs was not found to be true in this study. Percentage of total reimbursement attributed to drug costs for DRG categories studied (less than 4%) was consistent with previously acquired data in established DRG prospective payment programs. Average drug cost was not found to be a reliable indicator for comparison of drug utilization, either within DRGs or between hospital sites. Length of stay emerges as the primary focus for future efforts in drug utilization reviews and cost control programs. A model for future DRG-based drug utilization reviews is proposed.

Analysis of Variance↗
PubMedDate not supplied

Antibiotic cost-containment.

A multidisciplinary, professional, and administrative approach to selecting therapeutic agents for formulary inclusion--as it is practiced at the Tuskegee Veterans Administration Medical Center--is described. The process by which members of a Drug Utilization Review Subcommittee evaluate drugs is explained in detail. Numerous factors, such as patient population characteristics, total therapy costs, adverse reactions, indications, dosage, and efficacy are considered. Findings, decisions, and economic cost-savings, specifically with respect to antibiotics, are revealed.

Aged↗
PubMed2006

A senior care clerkship for pharmacy students.

OBJECTIVE: This paper describes a 200-hour senior care clerkship for pharmacy students over a five-year period from 1998-2003. SETTINGS: This clerkship used community long-term resources of a 160+ bed skilled nursing facility, adult day care, and senior citizen centers involving medicine, pharmacy, and nursing preceptors. PRACTICE DESCRIPTION: The facility consultant pharmacist was the primary preceptor of students. He conducted pharmacy rounds and daily patient case reviews three times per week. He provided monthly drug regimen review (DRR) and quarterly drug utilization review (DUR) to the skilled nursing facility and, as needed, consultation and therapeutic recommendations to the adult day care center and the senior citizen center. PRACTICE INNOVATION: A 200-hour clerkship was developed with multidisciplinary preceptor experiences to orient internal and external PharmD students to long-term care adult consultation with the attending physicians and nurses in the three sites. Each student prepared for physician rounds by performing an intensive DRR process for selected nursing facility patients. This included a preliminary discussion with the charge nurse on the unit and the consultant pharmacist. As directed, each rotation group proposed and completed one DUR project and written report. The overall goal was to enable the student to serve as a consultant pharmacist and, upon graduation, become a certified geriatric pharmacist. Rotation-specific objectives, evaluation instruments, and DRR and DUR processes are described. MAIN OUTCOME MEASUREMENTS: Documentation of contact time, completion of DRR and DUR activities, and interprofessional communication activities. RESULTS: There were 96 students who completed a 200-hour clerkship over five, 40-hour weeks during a five-year period from 1998 to 2003. Students evaluated some 10,000 patient-months of skilled nursing facility drug therapy and completed 20 DUR projects. All former students who have provided verbal feedback on their clinical training in this rotation have indicated that the rounds and conference contact with the medical director and med passes with the nurse were the key components in that they contributed most to effective interprofessional communication beyond what the consultant pharmacist preceptor offered. CONCLUSIONS: A senior care clerkship can be enhanced with medical director preceptorship in conjunction with the facility consultant pharmacist and nursing staff. This clerkship offered an experiential training that enabled pharmacy students to more effectively communicate with attending physicians and nurses, provide senior pharmacy care, and orient students to the opportunity for geriatric pharmacist certification.

Aged↗
PubMed2002

Impact of inappropriate drug use on mortality and functional status in representative community dwelling elders.

BACKGROUND: The predictive validity of Drug Utilization Review (DUR) and drugs-to-avoid criteria in elders is unknown. OBJECTIVES: To evaluate the relationship between use of inappropriate drugs as determined by these explicit criteria and mortality and decline in functional status in community dwelling elders. RESEARCH DESIGN: Cohort study. SUBJECTS: The fourth wave (3234 participants) of the Duke Established Populations for Epidemiologic Studies of the Elderly. MEASURES: Two sets of inappropriate drug-use criteria: (1) DUR with respect to dosage, duplication, drug-drug interactions, duration, and drug-disease interactions; and (2) Beers-modified criteria regarding drugs-to-avoid were applied to drug use reported in an in-home interview. Death was identified from the National Death Index; change in four functional status measures (basic self-care, intermediate self-care, complex self-management, physical function) was determined during the following 3 years. RESULTS: Use of inappropriate drugs identified by either set of criteria was not significantly associated with mortality. The drugs-to-avoid criteria identified no significant associations between use of these drugs and decline in functional status. With DUR criteria, however, the association between use of inappropriate drugs and basic self-care was significant and pronounced among those with drug-drug or drug-disease interaction problems (Adj. OR 2.04; 95% CI 1.32-3.16). CONCLUSIONS: Identifying the impact of inappropriate drug use may depend on the criteria applied. Further studies are needed that measure additional outcomes and use alternate measures of inappropriate drug use.

Activities of Daily Living↗
PubMed1984

Serum drug level utilization review in a family medicine residency program.

A total of 161 tests, comprising six of the most commonly ordered serum drug levels (SDLs) in a family medicine residency program, were audited retrospectively by a review panel. Audit criteria assessed the appropriateness of three factors associated with this laboratory test ordering procedure: (1) indication for the level, (2) procedure and documentation, and (3) physician utilization of the results. There were no statistically significant differences (P less than .05) when comparing the percentage of appropriate indications and uses with the individual drug levels ordered or with the number of years in practice. However, this audit indicated that a large number of therapeutic decisions were based upon information obtained from improperly ordered SDLs. Also, lack of proper documentation and charting of SDLs appeared to hamper optimal continuity of care in a clinic where patients were seen by several physicians. It is suggested that educational and administrative strategies may be effective in promoting better ordering and use of laboratory tests by family physicians in the future.

Adolescent↗
PubMed2002

Use of inappropriate prescription drugs by older people.

OBJECTIVES: To determine the prevalence and predictors of inappropriate drug prescribing defined by expert national consensus panel drug utilization review criteria for community-dwelling older people. DESIGN: Survey. SETTING: Five adjacent urban and rural counties in the Piedmont area of North Carolina. PARTICIPANTS: A stratified random sample of participants from the fourth (n = 3,234) and seventh (n = 2,508) waves of the Duke Established Populations for Epidemiological Studies of the Elderly. MEASUREMENTS: The prescribing appropriateness for digoxin, calcium channel blockers, angiotensin-converting enzyme inhibitors, histamine(2) receptor antagonists, nonsteroidal antiinflammatory drugs (NSAIDs), benzodiazepines, antipsychotics, and antidepressants as determined by explicit criteria (through Health Care Financing Administration expert consensus panel drug utilization review criteria for dosage, duplication, drug-drug interactions and duration, and U.S. and Canadian expert consensus panel criteria for drug-disease interactions). Multivariable analyses, using weighted data adjusted for sampling design, were conducted to assess the association between inappropriate prescribing and demographic, health-status, and access-to-healthcare factors cross-sectionally and longitudinally. RESULTS: We found that 21.0 of the fourth wave and 19.2 of the seventh wave participants who used one or more agents from the eight drug classes had one or more elements identified as inappropriate. The therapeutic classes with the most problems were benzodiazepines and NSAIDs. The most common problems were with drug-disease interactions and duration of use. Longitudinal multivariable analyses found that participants who were white (adjusted odds ratio (AOR) = 1.67, 95 confidence interval (CI) = 1.28-2.17), were married (AOR = 1.40, 95% CI = 1.01-1.93), had arthritis (AOR = 1.74, 95% CI = 1.27-2.38), had one or more physical function disabilities (AOR = 1.42, 95% CI = 1.02-1.96), and had inappropriate drugs prescribed at wave 4 (AOR = 6.87, 95% CI = 5.11-9.22) were more likely to have inappropriate prescribing at wave 7. CONCLUSION: These results indicate that inappropriate prescribing is common among community-dwelling older people and persists over time. Longitudinal studies in older people are needed to examine the impact of inappropriate drug prescribing on health-related outcomes.

Aged↗
PubMed1999

Drug use and prescribing problems in the community-dwelling elderly: a study of three state Medicaid programs.

This paper describes a study of drug use and drug-related problems in community-dwelling elderly (> or =65 years) Medicaid recipients in Maryland, Iowa, and Washington from 1989 through 1996. A claim-by-claim review of Medicaid prescriptions was conducted to detect 5 types of prescribing problems (dose, duration of therapy, duplicative therapy, drug-drug interactions, and contraindications or initial therapy). The study examined 8 drug categories: angiotensin-converting enzyme (ACE) inhibitors, antidepressant agents, antipsychotic agents, benzodiazepines, calcium channel blockers, digoxin, histamine2-receptor antagonists, and nonsteroidal anti-inflammatory drugs. The total number of persons with prescriptions in any of the 8 drug classes increased over the 8-year period, with the greatest growth in ACE inhibitors. Mean annual drug use per person declined in Maryland but increased in Washington and Iowa. Despite increasing use, the overall incidence of prescribing problems fell dramatically in all 3 states, particularly for dose- and duration-related criteria. Except in the area of drug-drug interactions, this elderly population was less likely to have received a prescription falling outside commonly accepted drug utilization review criteria for 8 major drug classes in 1996 than in 1989.

Aged↗
PubMed2004

Impact of inappropriate drug use on health services utilization among representative older community-dwelling residents.

BACKGROUND: There is limited objective information regarding the impact of drugs identified as inappropriate by drug utilization review (DUR) or the Beers drugs-to-avoid criteria on health service use. OBJECTIVE: The goal of this study was to examine the predictive validity of DUR and the Beers criteria employed to define inappropriate drug use in representative community residents, aged >or=68 years, as determined by the relationship of these criteria to health service use in older community residents. METHODS: Data came from participants in the Duke University Established Populations for Epidemiologic Studies of the Elderly seen in 1989/1990 and for whom information was also available 3 years later. Two sets of inappropriate drug use criteria were examined: (1) DUR regarding dosage, duration, duplication, and drug-drug and drug-disease interactions; and (2) the Beers criteria, applied to drug use reported in an in-home interview. Outpatient visits and nursing-home entry were determined by personal report; hospitalization information came from Medicare Part A files from the Centers for Medicare and Medicaid Services. RESULTS: A total of 3165 participants were available at the fourth interview in 1989/1990. The majority were aged >74 years (51.1%), white (64.8%), women (64.7%), had fair or poor health (77.0%), consistently saw the same physician (86.9%), and possessed supplemental health insurance (62.8%). Use of inappropriate drugs meeting DUR criteria, especially for drug-drug or drug-disease interaction problems, was associated with increased outpatient visits (P<0.05) but not with time to hospitalization or time to nursing home entry. The use of inappropriate drugs according to the Beers criteria was associated with reduced time to hospitalization (adjusted hazard ratio, 1.20; 95% CI, 1.04-1.39) but not to outpatient visits or nursing home entry. CONCLUSIONS: Our data suggest that in representative community residents aged >or=68 years, current criteria for inappropriate drug use should be used with caution in evaluating quality of care because they have minimal impact on use of health services. We found increases only in the use of outpatient services (with DUR) and more rapid use of hospitalization (with the Beers criteria).

Aged↗
PubMed2002

Changes in related drug class utilization after market withdrawal of cisapride.

BACKGROUND: Recent Food and Drug Administration-mandated and company-initiated withdrawals of drug products from the marketplace have had an impact on utilization in related drug classes. OBJECTIVE: To investigate the impact of withdrawal of the prokinetic agent cisapride (Propulsid) on utilization of other gastrointestinal (GI) agents. STUDY DESIGN: A longitudinal, retrospective study using electronic prescription data from a state-funded geriatric prescription benefit program. PATIENTS AND METHODS: Prescription claims for 2644 patients using cisapride between January 10, 2000, and October 1, 2000, were analyzed with respect to points in time at which (1) prospective drug utilization review edits were implemented denying reimbursement of cisapride because of drug interactions, (2) the manufacturer announced its intent to cease production, and (3) the agent was withdrawn from the market. Prevalence of use, claims volume, and expenditures were compared for cisapride, proton pump inhibitors, histamine-2 receptor antagonists, and the prokinetic agent metoclopramide during these periods. RESULTS: Use of cisapride decreased precipitately even before implementation of a "medical exception only" reimbursement policy. After the change in policy, metoclopramide use increased, although this increase was not proportional to cisapride's decline. Although total GI expenditures declined within the cisapride cohort, this change had little impact on overall program GI expenditures. CONCLUSIONS: The loss of cisapride did not significantly affect program-wide costs for GI drugs. However, the withdrawal of cisapride appears to have resulted in increased use of metoclopramide, a medication with a more serious adverse effect profile than cisapride. Further study is needed to evaluate the long-term clinical impact of such therapy changes.

Aged↗
PubMed1987

Effect of an educational intervention on oral cephalosporin use in primary care.

The prescribing of oral cephalosporin antibiotics in an ambulatory setting was evaluated before and after an educational intervention. A drug utilization review used previously developed criteria to study the indications, processes, complications, and outcome for oral cephalosporins in the outpatient setting. Baseline data were collected for one year in the initial phase of the study. Only one prescription (1.4%) in the initial phase (0.96% of the total) met the criteria for appropriate use. However, during the year after an educational intervention by a clinical pharmacist explaining the proper use of oral cephalosporins, the prescribing of these agents decreased substantially. Educational strategies in medical schools and residency programs that seek to improve drug-prescribing behavior should combine drug utilization review programs with specific education about the appropriate use of pharmacologic agents.

Administration, Oral↗
PubMed1997

Extent and variation of omeprazole prescribing in an elderly population of Ontario.

OBJECTIVE: To determine the extent of omeprazole prescribing in the senior population of Ontario over a 1-year period; the variation in omeprazole prescribing for this population according to age group, gender, and geographic region: and the extent of inappropriate prescribing of omeprazole for this population. DESIGN: Retrospective drug utilization review of prescription drug insurance claims. DATA SOURCE: The Ontario Drug Benefit (ODB) program claims database. OUTCOME MEASURES: The following outcomes were measured: the proportion of seniors in Ontario who received a prescription for omeprazole from April 1, 1992 to March 31, 1993: effects of age group, gender, and geographic region of residence on omeprazole prescribing; and the extent of inappropriate omeprazole prescribing according to the ODB criteria for use. Prescribing of omeprazole was defined as inappropriate if a first-line antiulcer drug (i.e., histamine2-receptor antagonist) was not prescribed within 1-6 months of the first prescription claim for omeprazole. RESULTS: A total of 29,936 seniors in Ontario received omeprazole from April 1, 1992 to March 31, 1993 (2.53 recipients per 100 eligible population). The age-gender group most frequently prescribed omeprazole was women 65-74 years, followed by women and men 75 years or older, and then men 65-74 years. Omeprazole prescribing varied widely among the 48 provincial counties (range of 1.66 recipients per 100 eligible population to 4.52 recipients per 100 population, p < 0.001). There was no evidence of a clustering effect in omeprazole prescribing at the county level. Prescribing of omeprazole was considered to be inappropriate for 80.5% of recipients. CONCLUSIONS: This study demonstrated the ineffectiveness of the ODB limited-use program in controlling omeprazole prescribing. Further study should be done to examine determinants of variation in prescribing by geographic region.

Age Factors↗
PubMed1993

Pharmacy practice acts: a five-year follow-up.

OBJECTIVE: To rereview the status of state pharmacy practice acts since 1987. Additionally, this report discusses adoption of the 1992 National Association of Boards of Pharmacy Model State Pharmacy Practice Act as the standard state pharmacy practice statute. DATA SOURCES: State codes for 50 states and the District of Columbia, with attention focused on the pharmacy practice acts; Puerto Rico and the Virgin Islands were excluded. CASE LAW SELECTION: Case law utilizing state pharmacy statutes was selected to demonstrate pharmacists' liability. DATA EXTRACTION: The focus on each statute was the statutory definition of the "practice of pharmacy." DATA SYNTHESIS: Twelve pharmacy laws (24 percent) contain no definition of the practice of pharmacy. Compounding (92 percent), dispensing (100 percent), interpretation and evaluation of prescriptions (72 percent), consultation (85 percent), drug utilization review (69 percent), drug product selection (54 percent), drug administration (21 percent), pharmacokinetic consultation and patient assessment (13 percent) were noted in the laws for the remaining 38 states and the District of Columbia. Significant pharmacy activities codified since 1987 include consultation, drug administration, pharmacokinetic consultation, and patient assessment. Statutes defining pharmacy practice impact the profession by affecting liability and by mirroring society's view of the role of the profession. CONCLUSIONS: States have enacted new statutes principally in the areas of progressive pharmacy practice functions since 1987. Enactment of the definition of professional practice contained in the National Association of Boards of Pharmacy Model State Pharmacy Practice Act would serve the pharmacy profession by: (1) creating a uniform professional purpose; (2) creating legal responsibility that reflects contemporary practice; (3) allowing pharmacists to enlarge the scope of their practice as the profession's societal role evolves; and (4) conserving revenues normally consumed by lobbying for constant legislative revisions.

Data Collection↗
PubMed1977

Undergraduate medical education in geriatrics: nursing home experience.

Preclinical medical students undertook an elective course in geriatrics which combined instruction in history taking, physical diagnosis, and problem-oriented assessment of elderly patients in a nursing home. A drug utilization review and specific drug therapy plans were formulated by pharmacy students. The project identified general problems susceptible to institutional as well as individual remedy. The students were led beyond their initial preoccupation with "physical complaints" to interest in pertinent psychological, social, and economic factors. A model of geriatric education for health science students can productively link the health science center and community nursing homes with benefits for the student, the patient, and the nursing home.

Aged↗
PubMed2005

Examining nurses' decision process for medication management in home care.

BACKGROUND: The process of medication management within home care agencies was prospectively described, with a focus on the nurse's role and critical points in the process. The process the nurse must follow includes preparing, checking, and administering medications; updating knowledge of medications; monitoring the effectiveness of treatment; reporting adverse reactions; and teaching patients about their drugs. PROCESSES FOR MEDICATION MANAGEMENT IN HOME HEALTH CARE: The steps that home health nurses (HHNs) go through with families and the system changes that could be developed to decrease errors were identified. The approach was based on Failure Mode and Effects Analysis-a method to identify and prevent process problems before they occur. The medication management process was divided into drug utilization review (DUR) for duplicative and harmful interactions; drug administration by the patient, family member, and/or caregiver; and side effects. Failure modes were developed for a DUR for duplicative and harmful interactions. DISCUSSION: Home health agencies should analyze the medication management process in their own agencies and identify system solutions. The difficulty encountered by HHNs in contacting physicians to discuss changes to the drug regimen following the assessment of potential drug interactions or duplications is an ongoing problem. Careful monitoring by HHNs could decrease the impact of adverse drug effects.

Decision Making↗
PubMed1996

Medication prescribing advice and drug utilization: a review from the United Kingdom.

General Medical Practitioners (GPs) in the United Kingdom are usually the first point of contact with the National Health Service (NHS) for patients. They provide the majority of ambulatory care for their practice population and act as 'gatekeepers' for referral onwards to other services. This article investigates the influence of the purchasing authority prescribing advisors (PAs), including pharmacists and GPs on the prescribing habits in Salford, England, an inner city area in the North of England, close to the city of Manchester. The PAs became known as the prescribing CIA, and used the strategy of Control, progressing to Influence and Autonomy, to develop a mature partnership between the GPs, PAs and other health care professionals. Information collated from prescribing (PACT) data, by the Prescription Pricing Authority, was used to make comparisons between different practices within an area. Savings made by making rational changes in prescribing, were used to enhance practice development for the benefit of patient care.

Data Collection↗
PubMed1984

Drug utilization study of antiepileptics in Hungary.

This paper describes drug utilization review activities on anticonvulsant drugs in Hungary. Data on the use of phenytoin, carbamazepine, primidone, and sulthiam in the 20 administrative regions of the country are presented. From 1971 to 1980, consumption of these anticonvulsants doubled, and most of them were used in combination therapy. Estimates of the numbers of epileptics in the country were calculated from data on the international incidence of epilepsy and from total drug consumption data in Hungary.

Anticonvulsants↗
PubMed2004

Evaluation of a physician-focused educational intervention on medicaid children with asthma.

BACKGROUND: The 1990 Omnibus Budget Reconciliation Act mandated drug utilization review in response to inappropriate drug use. In the Pennsylvania Medicaid program, pediatric asthma is associated with high healthcare utilization and cost. OBJECTIVE: To determine the effects of a physician-focused educational intervention on asthma drug use and healthcare utilization. METHODS: Pre- and postintervention comparison design was used in children 5-18 years of age who were enrolled in the Pennsylvania Medicaid fee-for-service program from July 1, 1998, to March 31, 1999 (preintervention), and July 1, 1999, to March 31, 2000 (postintervention). The intervention packet included patients' drug profiles, medical history, monograph with national asthma management guidelines, and patient education materials to physicians. Main outcome measures are changes in asthma drug utilization among high-users of short-acting beta(2)-agonists (SAB). RESULTS: The intervention focused on 2 asthma drug use criteria: (1) high-use of quick-relief medication and (2) use of salmeterol without the availability of a quick-relief medication. The intervention reduced quick-relief medication use by 26% among patients with higher use without significant changes in long-term control drugs. In addition, 82% of the recipients evaluated had a positive change in salmeterol utilization as either having an SAB inhaler added after the intervention or salmeterol discontinued after the intervention. There was no significant change in asthma-related emergency department visits or hospitalizations. CONCLUSIONS: Although the physician responders agreed on the usefulness of the educational materials, the results suggest that the intervention had limited success in improving the pharmacologic management and no effect on the health outcomes. We believe that mailed educational materials to physicians can be effective to change prescribing behavior; however, a more multifaceted intervention may be necessary to improve health outcomes.

Adolescent↗
PubMedDate not supplied

The role of pharmacy computer systems in preventing medication errors.

OBJECTIVE: To describe the controversies and review the evidence about computer-aided prospective drug utilization review (PDUR) systems. DATA SOURCES: MEDLINE search of the literature. STUDY SELECTION: Published studies of the effectiveness of computer-aided prescription screening. DATA SYNTHESIS: One randomized, controlled trial and four nonrandomized studies constitute the evidence base. The five studies are inconclusive with respect to whether computer-aided prescription screening causes health care providers to take action, either because of a no difference finding or because there was no comparison group. In the one randomized, controlled trial, a substantial number of actions were taken by the control group whose members did not receive alerts. No study evaluated the total effect of screening by in-store and payer (online) systems. Specific research recommendations are made to increase the evidence base. CONCLUSION: Limited and inconclusive evidence about whether these systems are effective and what system features are optimal may explain the wide variation among systems in terms of what problems are screened and may also explain clinicians' uncertainty about their value. A comprehensive national research agenda for reducing medical errors should include research on the effectiveness of computer-aided PDUR.

Computer Systems↗