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PubMed1994

Prescription drug utilization review in the private sector.

With increased coverage of prescription drugs by health insurance plans, utilization data are now becoming available and there is renewed interest in drug utilization review (DUR) programs. This article describes the DUR programs now being conducted by private sector firms for health insurance plans. The programs were found to be highly automated and very efficient. Most firms estimate at least two to three dollar direct savings for each dollar invested in DUR. Much of this results from controlling overutilization and gaining compliance with drug formulary guidelines. In addition, the firms report finding drug therapy problems in about two to three percent of the enrollees receiving prescriptions.

Chemistry, Pharmaceutical↗
PubMedDate not supplied

Current status of prospective drug utilization review.

BACKGROUND: The Omnibus Budget Reconciliation Act of 1990 offered the promise that prospective drug utilization review (pDUR) systems would improve the quality of drug prescribing and patient drug use. There is little evidence that this promise has been fulfilled. To the contrary, there is growing evidence that suboptimal use of drugs (in terms of preventable drug-related morbidity) is at least as costly as the prescription drugs themselves. Online computerized pDUR has been the subject of numerous critical examinations in the pharmacy and medical literature. Recent publications have sought to illustrate perceived shortcomings in the DUR systems currently in use. OBJECTIVE: We focus on the state of the art with regard to pDUR, what is known about its effectiveness, and how emerging technologies may change pDUR and consider the work that may be needed to establish its effectiveness. SUMMARY: A growing body of literature documents numerous problems and concerns with respect to the quality of DUR criteria, DUR alerts, and the response of health care professionals to these alerts. Problems with the current pDUR "system" can be grouped into those involving technical aspects (e.g., duplicate messaging from in-store and online systems, or message text limitations) and into those involving human aspects, specifically how pharmacists and other health care providers interpret and respond to potential drug therapy problem alerts generated by the electronic systems. CONCLUSION: DUR is a quality assurance system that holds promise as a tool that, if implemented effectively, could enhance appropriate drug use. We believe a more systematic approach to DUR is needed. Evaluation and management of public and private pDUR systems must link documentation of processes of care, such as pharmacists. cognitive services, patient interventions, etc. To address technical aspects, we strongly recommend (a) a national effort to validate DUR screen criteria relying upon evidence-based studies and (b) adoption of a minimal set of.critical. pDUR screen criteria by pharmacy service providers and third-party intermediaries, including pharmacy benefit managers. To address the human component of pDUR systems, we advocate (a) adoption of performance standards for pharmacists and (b) explicit remuneration for time spent identifying and responding to drug therapy problems.

Drug Therapy↗
PubMed1986

The defined daily dose system (DDD) for drug utilization review.

The defined daily dose (DDD) system for use in utilization studies is presented for consideration by pharmacy and therapeutics committee members as an additional tool for drug utilization review and drug regimen review activities. The article describes the development and nature of the DDD system and provides examples of its format, benefits, and limitations. Essentially, the DDD system was devised by the Nordic Council on Medicines, and the early work was done in Norway with the Anatomical Therapeutic Chemical (ATC) diagnostic code system. Whereas consumption andutilization studies in North America have focused on the prescribing by an individual physician and drug utilization for an individual patient, the Scandinavians have attempted a macroscopic focus on the total consumption of drugs for a county or country or other definable political or geographic region. The sale of the drugs is divided by what is agreed on as an average daily dose to yield a unit of measure called the DDD, which is valuable for comparative studies. The DDD system and its component aspects are presented so that hospital pharmacists may evaluate its benefits for potential use in North America.

Drug Utilization↗
PubMed1975

Utilization review of treatment of suicide attempters: chart review as patient care evaluation.

The authors reviewed the charts of 36 nonhospitalized suicide attempters who were identified by utilization review as requiring hospitalization. In 16 of the cases, the authors judged the treatment given to have been adequate because of an absence of a history of psychiatric treatment and/or the rapidity with which outpatient treatment was instiituted. Ten of the cases were judged to have been inadequately treated. This finding pointed to have been inadequately treated. This finding pointed to specific deficiencies in the training of residents and the delivery of psychiatric services and illustrates how chart review can be used to upgrade psychiatric care.

Adolescent↗
PubMed1981

Drug utilization review: a practical approach.

Described is a method to perform drug utilization review retrospectively by using mutually exclusive categories. Drug use criteria were developed and structured in such a manner so that a patient's drug use experience could be readily and appropriately classified by medical records technicians during the routine medical record abstraction. Utilizing a contract abstracting service format, a summary by category of drug use experiences for the patients audited is provided monthly and used as the preliminary audit summary. The system represents an efficient and cost-conscious means of effectively monitoring selected portions of the drug utilization process.

Drug Utilization↗
PubMed1990

The design and effectiveness of a graduate survey course in quality assurance and utilization review.

This paper reports on the design, presentation, and evaluation of a graduate university course in quality assurance and utilization review. The authors cite the need for expanded course offerings in this field and present descriptions of the course design and student participants, including program location, objectives, learning themes and content, instructor team, students, and course process. Student feedback is reported including comments on course strengths and needs, teaching methods, and learning evaluation. Additional work requirements are cited.

Curriculum↗
PubMed1990

Relating health care market characteristics to the effectiveness of utilization review programs.

This paper presents an exploratory analysis of the relationships between several health care market characteristics and the effectiveness of utilization review programs directed at controlling hospital use and expenditures. The analysis is based on claims data from 223 insured groups over 12 quarters. Results indicate that UR is associated with larger reductions in utilization and expenditures in markets with low HMO enrollment, high admissions per capita, and low hospital occupancy rates. These results suggest that health care market conditions that permit unnecessary use are the ones under which UR programs can be most effective.

Cost-Benefit Analysis↗
PubMed1976

Quality assurance: the cost of utilization review and the educational value of medical audit in a university hospital.

The components of mandated quality assurance, that is, utilization review (UR) and medical audit, have been analyzed to determine their cost-effectiveness and educational value in a university hospital. At Ths in 1975 were $205,272--$6.71 per admission or $0.69 per patient day. The average costs per admission and per patient day in teaching hospitals in the New York area in 1975 were $10.42 and $0.93, respectively. It is anticipated that these costs will increase markedly in 1976 because of admission review. Since 1972 approximately 9,500 hospital charts have been reviewed annually to identify an average of six patients per year who required the intervention of the UR committee because of unnecessarily prolonged length of stay. The cost of identifying each patient was $33, 212. In the university hospital, the active participation of the graduate (house) staff in patient care renders the requirements for certification/recertification of the need for hospital services or admission review superfluous. From September, 1973, through December, 1975, 15 studies of evaluation of medical care (medical audit) have been completed at an average cost of $4,788 per audit. In ten audits the principal criticism was inadequate documentation of data in the hospital record. Nine audits were critical of excessive use of laboratory services and deviations of practice were identified in seven audits. Medical audit has failed to achieve its objective to identify the educational needs of the hospital staff. It is suggested that a more satisfactory and less costly form of medical audit should be devised. Clinical studies, published in scientific journals, should be considered in the context of medical audit.

Adolescent↗
PubMed1996

Retrospective drug utilization review software systems: perspectives of state Medicaid DUR directors.

OBJECTIVE: To determine the desirability or perceived need of retrospective drug utilization review (DUR) software system characteristics. DESIGN: A 32-item questionnaire. SETTING: Ambulatory DUR directors covering more than 33 million patients. PARTICIPANTS: Medicaid DUR directors from 49 states and the District of Columbia. MAIN OUTCOME MEASURES: Five-point Likert scale measures of importance of system and vendor characteristics. RESULTS: A 100% response rate was achieved. Respondents rated the ability to change or modify criteria as very important and thought it was important to receive criteria sets from software vendors. Respondents believed cost-savings methodologies should be clearly defined and false positive DUR criteria should be minimized. CONCLUSIONS: Through the implementation of the Omnibus Budget Reconciliation Act of 1990, considerable experience in ambulatory DUR programs has been achieved. Respondents believed the ability to change DUR criteria was very important and they thought it was important to have a set of criteria supplied from software vendors. Critical issues of criteria development, cost-savings methodologies, minimizing false positive criteria, and outcomes assessment from DUR programs were important issues to DUR directors.

Drug Therapy↗
PubMed1995

The evolution of hospital utilization review methods in the United States.

The purpose of this paper is to provide a description of utilization review (UR) methods that have been used in the United States and the direction UR is likely to take in the future. In contrast to the European studies reported in this issue, which consist primarily of empirical studies quantifying the magnitude of inappropriate hospital utilization, the focus of this paper is on the methods used to perform UR operationally. Particular attention will be paid to the predominant form of UR employed in the United States, concurrent review of the need for a hospital level of care, and on the criteria used to assess appropriateness of hospital admissions and days.

Forecasting↗
PubMed1979

Using the PAS system for hospital drug utilization review.

The PAS system, subscribed to by many hospitals, is readily adaptable to drug usage review. Useful for this purpose are PAS data on drug usage according to (1) drug type, (2) diagnosis, and (3) information supplied at patient admission. The PAS system also permits "special coding," or "targeting," of other data for review. Whatever the drug utilization system used, pharmacist input into the process is highly important.

Commission on Professional and Hospital Activities↗
PubMed1990

The fellowship program in quality assurance and utilization review. A two-year report.

This article reports on the progress of a fellowship program for physicians in quality assurance and utilization review (QA/UR). The article begins with a description of the initial program concept and presents the "program-in-action" including: academic coursework, site rotations, learning experiences of the fellow/resident, funding, outcomes to date, strengths and weaknesses analysis, current requirements, and future research and development needs. By presenting design and operations this 2-year progress report is intended to assist other developing programs as QA/UR education increases nationally.

Education, Medical, Continuing↗
PubMed1990

Characteristics of applicants to the fellowship program in quality assurance and utilization review.

This article presents the first data on the characteristics of applicants to the physician fellowship program in quality assurance (QA) and utilization review (UR). Data presented about applicants include demographic characteristics, board and national certifications, specialties, license type, practice experience, and QA and UR experience. These data were obtained from individual applications for admission to the program. They are used here to create a database for the program to generate future information on this new specialty group. Characteristics of current applications selected begin to define the members of the profession.

Data Collection↗
PubMedDate not supplied

Retrospective drug utilization review and the behavior of Medicaid prescribers: an empirical marginal analysis.

The objectives of this study were to evaluate the effectiveness of drug utilization review (DUR) letter intervention on reducing the cost of medications under Medicaid. The target drugs in this study were six antiulcer agents prescribed for Alabama Medicaid recipients. The study group consisted of 100 prescribers who received DUR intervention. A total of 3776 prescribers who did not receive DUR intervention served as the comparison group. Using an interrupted time series design, these 3876 prescribers were studied before and after the implementation of the DUR program. The study found that prescribers' behavior changed after the DUR letter were sent out, resulting in a reduction in the average marginal days of drug therapy and drug reimbursement per recipient. For the target drugs, there was an average savings of $112.73 per prescriber per month and a total of $136,370.82 savings per month for the Alabama Medicaid program.

Alabama↗