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PubMed1994

Evaluation of a DUR intervention: a case study of histamine antagonists.

Drug Utilization Review (DUR) programs aim to control inappropriate prescribing and drug costs, but there are few rigorous studies of their impact. This paper presents the evaluation results of a DUR intervention (excessive duration of full-dose histamine-2 receptor antagonists) using a quasi-experimental design. We observe a greater reduction of H2RA use in the intervention group than in the comparison group, and a reduction in drug expenditures which exceeded the cost of targeting and notifying prescribers. The success of DUR programs depends on both their efficiency and the drug issues under consideration; the use of a comparison group is critical in the evaluation of their impact.

Ambulatory Care↗
PubMed2003

Approaches to pharmacy benefit management and the impact of consumer cost sharing.

BACKGROUND: Numerous mechanisms have been introduced to deliver prescription drug benefits while controlling pharmaceutical costs. An understanding of the most prominent mechanisms of benefit management is an important step in determining the most effective approach to take in future years. OBJECTIVES: The aims of this review were to illustrate the mechanisms by which managed care has attempted to efficiently and equitably deliver pharmacy benefits and to discuss the impact of such programs, including consumer cost sharing. METHODS: A review of the literature was conducted using the PreMedline and MEDLINE databases from the years 1966 to 2002, reference lists from relevant articles, and online sources, including news releases, conference materials, and pharmacy benefit management reports. RESULTS: Numerous pharmacy benefit management tools and their impact on utilization, expenditures, and health outcomes are reviewed, including disease state management; utilization management (ie, quantity limitations and prior authorization); drug utilization review; formulary management (ie, open and closed); delivery systems (ie, retail and mail order); and mechanisms for implementing consumer cost sharing (ie, generic incentives, multitiered copayments, and co-insurance). Although there is some evidence to suggest that certain benefit management tools have been successful in reducing health plan expenditures, a more thorough investigation of their potential unintended consequences is needed. CONCLUSIONS: Implementing adequate levels of consumer cost sharing is necessary if employers and health plans are to continue offering prescription drug benefits. It is important to remember, however, that quality health care cannot be forfeited for the sake of short-term cost savings.

Community Participation↗
PubMed2004

Evaluation of angiotensin-converting enzyme inhibitor use in patients with type 2 diabetes in a state managed care plan.

OBJECTIVE: To compare angiotensin-converting enzyme (ACE) inhibitor use in patients with type 2 diabetes at 1 year and 3 years after guidelines were published. STUDY DESIGN: Retrospective database review. PATIENTS AND METHODS: The drug utilization review database of a state managed care plan was accessed to retrieve 2 random samples of 500 patients each. These patients had an International Classification of Diseases, Ninth Revision, Clinical Modification code for diabetes mellitus (250) and a National Drug Code for an oral hypoglycemic agent in both 1998 and 2000. Specific clinical modification codes, prescription claims, and diagnostic codes were obtained from patient profiles. Use of ACE inhibitors in 1998 and 2000 then was evaluated by using Pearson's chi-square test. RESULTS: The proportion of patients with diabetes and hypertension who were taking an ACE inhibitor increased by 10 percentage points over the 2 years; however, ACE inhibitors were only used in 46% of those patients in 2000. A few of the patients receiving an ACE inhibitor had a contraindication to use of the agent. Microalbuminuria screening and glycosylated hemoglobin screening were found to have been conducted in only 4.6% and 54.6%, respectively, of the 496 patients in 2000. CONCLUSIONS: The results of this study indicate that although ACE inhibitor use improved, fewer than 50% of patients received appropriate therapy. Awareness of and adherence to the recommendations in the guidelines need to be improved. Larger studies may be beneficial to determine more clearly the extent of this problem.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1992

DUE software highlights therapeutic issues.

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

Drug Prescriptions↗
PubMed2006

Analysis of anti-epileptic drugs in fee-for-service Wisconsin Medicaid.

INTRODUCTION: Off-label use of prescription drugs presents issues of patient safety and can significantly increase the overall prescription drug expenditure in providing health care services. As a class, the anti-epileptic drugs are provided for off-label use on a frequent basis. Because of the safety issues and increased cost with such prescribing practices, the Wisconsin Medicaid Drug Utilization Review Board (DUR board) reviewed the use of anti-epileptic agents in the fee-for-service Wisconsin Medicaid population. METHODS: Prescribers with the highest amount paid for drugs in this class, and for which there was no appropriate diagnosis (intervention group), were provided with a list of the patients for whom they prescribed the drug for an off-label clinical condition. A total of 488 prescribers were contacted and informed of the costs and hazards of off-label prescribing. RESULTS: Using a comparison group of patients who were prescribed anti-epileptic agents but who did not reach the amount paid threshold (non-intervention group), the study demonstrated a decrease of 6652 prescriptions in the intervention group and an increase of 4194 in the non-intervention group. In addition, expenditures for the intervention group dropped by dollar 752,232 and the non-intervention group rose by dollar 835,351. It is estimated that the overall financial impact of this intervention was a savings of dollar 2,552,077 over the 5-month period of review.

Anticonvulsants↗
PubMed2003

Update on drug-related problems in the elderly.

BACKGROUND: Although pharmacotherapy for the elderly can treat diseases and improve well-being, its benefits can be compromised by drug-related problems. OBJECTIVE: This article reviews recent publications concerning drug-related problems in the elderly, as well as articles describing the development of 3 sets of quality indicators for medication use in the elderly. METHODS: Relevant articles were identified through a search of MEDLINE (2002-March 2003) for articles on drug-related problems, inappropriate prescribing, and adverse drug events in the elderly. RESULTS: The review included 7 articles published in 2002 and 2003. A study in ambulatory elderly persons reported that approximately 5.0% of patients had > or =1 adverse drug event within the previous year. Another study found that approximately 20.0% of ambulatory elderly persons used > or =1 inappropriate drug, as defined by drug utilization review (DUR) criteria, with drug-disease interactions and duration of use being the most common drug-related problems. A third study involving elderly individuals in assisted living facilities found that 16.0% used > or =1 inappropriate drug, as defined by the Beers criteria. Another study examined whether inappropriate drug use, as defined by the Beers or DUR criteria, was associated with death or a decline in functional status; it found that only use of drugs defined as inappropriate by DUR criteria (particularly those drugs associated with drug-drug or drug-disease interactions) was associated with a decline in the ability to perform basic self-care. Three studies, 1 from the United States, 1 from the United Kingdom, and 1 from Canada, described consensus development of quality indicators for drug use in the elderly, including drugs to avoid, maximum daily dose, drug duplication, limits on duration of use, drug-drug and drug-disease interactions, need for drug monitoring, underuse of necessary drugs to treat or prevent common problems, and inappropriate drug-administration technique. CONCLUSIONS: Drug-related problems are common in elderly patients. Data from recently published studies provide guidance to practitioners and directions for future research.

Age Factors↗
PubMedDate not supplied

Determining physicians' knowledge and attitudes when prescribing drugs to treat gastrointestinal disorders.

OBJECTIVE: Peptic ulcer disease (PUD) affects 10% to 15% of the US population. The causes of PUD are many, including high acid production, low bicarbonate secretion, and infection due to Helicobacter pylori. In 1992, the Vermont Medicaid Program noted a significant increase in prescription drug expenditures, particularly in the area of treatment of PUD. The purpose of this study was to review Medicaid prescription data and to use focus group methodology to gain an understanding of rural nonacademic and semiurban academic physicians' prescribing decisions regarding the treatment of PUD. METHODS: Pharmaceutical data from 1991 and 1992, provided by the Department of Social Welfare, Medicaid Division, was reviewed. Focus group discussions were held with primary-care providers from rural and semiurban regions with Vermont. RESULTS: Pharmaceutical review revealed that expenditures increased 21% for gastrointestinal drugs from 1991 to 1992. Drug utilization review of pharmaceutical prescriptions revealed that H2 antagonists were being prescribed for greater than the recommended 6 to 8 weeks in 60% of the cases. Focus group discussions showed that rural nonacademic and urban academic physicians had similar concerns and management plans in regard to their patients with peptic ulcer disease. However, differences existed in physician perceptions regarding pharmaceutical effectiveness of various agents for the treatment of PUD. CONCLUSIONS: Physician education outreach programs should be designed to standardize treatment methodology for PUD throughout the state. This standardization of treatment could have a significant impact on healthcare costs and the ease with which patients can eradicate this disease.

Clinical Competence↗
PubMed1996

Formulary: what it is and how it works.

Estimates for healthcare expenditures in 1993 exceeded $900 billion, approaching 15% of GNP. Of this, approximately 7.5% ($62 billion) was spent on drugs. More recently, costs show that the US spends over $3,000 per person per year on healthcare. Although no one disputes that the cost of healthcare is rising, generally the rate at which it rises is not as rapid in a managed care environment compared to a fee-for-service one. Because of this, the boundaries of managed care and pharmacy benefits management (PBM) continue to expand. Outpatient drug benefits, for instance, are being carved out of the medical benefit offered by several types of insurance programs. This is mainly a result of point-of-sale claims processing and enhanced information system data base reporting making the drug portion easier to identify and separate from other medical claims. Self-funded employers are now actively seeking PBM companies to contract with for this type of service. The services being offered by PBM companies include: Pharmacy networks in which plan members fill prescriptions at a discounted or contracted rates. Disease state management. Drug utilization review. Financial reporting. Formulary management. The main component of formulary management is the development and distribution of a drug formulary. This article discusses what a drug formulary is and how it works.

Cost-Benefit Analysis↗
PubMed1996

The involvement of pharmacists in professional and clinical audit in the UK: a review and assessment of their potential role.

This review addresses the uptake and implementation of the principles of audit by community, hospital and health authority pharmacists. The pressures to audit professional services are discussed, as are the barriers to cooperation among pharmacists and between pharmacists and prescribers in primary care. The development of standards of professional practice is then described taking into account the particular difficulty in developing standards for health care workers who are geographically separated from other members of the primary care team and are in commercial competition with each other. The review identifies audit of professional services in both community and hospital pharmacy and of clinical services in the latter. The role of pharmacists employed by health authorities to advise them and general practitioners on the optimum use of the drug budget is described and their potential role for involvement in audit is discussed. The particular advantages that pharmacists in hospital and health authorities have in developing the specific aspect of clinical audit related to medicines usage (drug utilization review) is then described. The potential for pharmacists to contribute to clinical and management audit is discussed.

Community Pharmacy Services↗
PubMed2001

Drugs and the elderly, Part 2: Strategies for improving prescribing in a managed care environment.

OBJECTIVE: In part 1 of "Drugs and the Elderly" (December 2000 issue), we reviewed and summarized the vast amount of clinical information on medication use in the elderly for healthcare providers and administrators within managed care. In part 2, we explore the literature on improving prescribing, focusing on those approaches most likely to be useful within a managed care environment. STUDY DESIGN: We reviewed the general literature on medication use in the elderly, focusing on problems and systems approaches to the improvement of medication use in managed care. We created a topic list of general interest to health professionals within managed care and fit the available information into those topics. Thus, the result is an authoritative review rather than a systematic literature review. PATIENTS AND METHODS: Nonquantitative evaluation of the medical literature. RESULTS: We identified several hundred articles describing issues related to medication use in the elderly but only a trivial number that in any way addressed the managed care community directly. There is very little literature on how managed care can best incorporate the lessons of geriatric pharmacology and pharmacy. CONCLUSIONS: There is a paucity of literature for the managed care community of health professionals regarding pharmacology, pharmacoepidemiology, drug utilization review, and other issues related to the use of medication in the elderly population.

Aged↗
PubMedDate not supplied

Effect of patient information on the quality of pharmacists' drug use review decisions.

OBJECTIVE: To evaluate the effect of incremental increases in patient information on the quality of pharmacists' clinical decisions related to legally mandated prospective drug utilization review (DUR) responsibilities. DESIGN: Unblinded comparison of two groups. PARTICIPANTS: 28 community pharmacists in Indiana (group 1) and 32 Public Health Service pharmacists employed in the Indian Health Service (IHS) (group 2). INTERVENTIONS: Clinical cases involving prescribing problems were developed from patient charts. Each case contained four levels of increasing patient information: Level 1 included only information required for a legal prescription in Indiana; Level 2 added the patient's current medication profile, age, and allergies; Level 3 added the diagnosis or reason for use of the prescribed medication; and Level 4 added the physician's progress note. Pharmacists were asked to evaluate the prescribed drug therapy at each level of each case and complete a Dispensing Appropriateness Index (DAI) report, which included all prospective DUR criteria required by the Omnibus Budget Reconciliation Act of 1990. The quality of pharmacists' DUR decisions at each level of patient information was evaluated by comparing pharmacists' responses on the DAI reports with the consensus judgment of two clinical experts. RESULTS: The quality of both community and IHS pharmacists' DUR decisions improved significantly at each incremental level of patient information. CONCLUSION: Pharmacists in this study made better decisions when they had access to more complete patient information on which to base their decisions.

Adult↗
PubMed2000

Drugs and the elderly, Part 1: The problems facing managed care.

OBJECTIVE: In part 1 of "Drugs and the Elderly," we review and summarize the vast amount of clinical information on medication use in the elderly for healthcare providers and administrators within managed care. In part 2, we explore the literature on improving prescribing, focusing on those approaches most likely to be useful within a managed care environment. STUDY DESIGN: We reviewed the general literature on medication use in the elderly, focusing on problems and systems approaches to the improvement of medication use in managed care. We created a topic list of general interest to health professionals within managed care and fit the available information into those topics. Thus, the result is an authoritative review rather than a systematic literature review. PATIENTS AND METHODS: Nonquantitative evaluation of the medical literature. RESULTS: We identified several hundred articles describing issues related to medication use in the elderly but only a trivial number that in any way addressed the managed care community directly. There is very little literature on how managed care can best incorporate the lessons of geriatric pharmacology and pharmacy. CONCLUSIONS: There is a paucity of literature for the managed care community of health professionals regarding pharmacology, pharmacoepidemiology, drug utilization review, and other issues related to the use of medication in the elderly population.

Aged↗
PubMed1997

Drug education. Moving ahead the fourth year.

The Omnibus Budget Reconciliation Act (OBRA) of 1990 required all states to implement drug utilization review programs for outpatient medications covered by Medical Assistance. This second of a two-part series outlining the activities of the State Society's Center for Professional Drug Education and Information discusses the effectiveness of Pennsylvania's program.

Drug Utilization Review↗
PubMed2001

Use of systemic anti-infective agents in Iran during 1997-1998.

OBJECTIVE: Conduction of standardized national drug utilization review to investigate the pattern of systemic anti-infective agent use in Iran. METHODS: The wholesale data were used. The Anatomical Therapeutic Chemical (ATC) classification and the defined daily dose (DDD) methodology was employed. Data were presented as DDD/1,000 inhabitants"day. Results were compared using national drug statistics of Norway, Sweden, and Denmark. RESULTS: The overall sales of systemic anti-infective agents was 43.5 DDD/1,000 inhabitants/day. The parenteral form of drug accounted for 4.20% and broad-spectrum systemic antibacterial agents accounted for 86.2%. The three most commonly used agents, accounting for 74.1% of total sales, were amoxicillin, co-trimoxazole, and ampicillin. Seven kinds of anti-infective agents (17% of total available agents) accounted for 90% of antibacterial use, with dominance of broad-spectrum agents. Comparison showed differences in pattern and intensity of use. The sales of systemic anti-infective agents in general, particularly antibacterials and anti-tuberclotics, were greater in Iran than in three European countries. Broad-spectrum antibacterial agents accounted for a larger proportion of total sales in Iran. CONCLUSION: The high use of systemic antibacterial agents in general, particularly broad-spectrum agents, suggest the possibility of irrational prescribing, higher prescribed daily doses than DDDs, and a drug wastage. This survey, as a first attempt, provided an overview of anti-infective use in Iran. Thus, it may serve as a basis for further investigative studies and advanced drug policies.

Amoxicillin↗
PubMed1998

Pharmacotherapy: strategies to control drug costs in managed care.

Pharmacotherapy remains one of the most cost-effective interventions physicians can provide to manage the medical conditions of older patients. Because many older Americans have multiple diseases, the practitioner's goal is to maximize appropriate drug use while avoiding duplicative or interacting medications. Medicare managed care plans seek to provide appropriate medication for the older patient at a reasonable cost through such strategies as formularies, prior authorization, generic and therapeutic substitution, and drug utilization review. Yet, like the medications themselves, these strategies require careful attention to their risks and benefits to the individual patient.

Drug Costs↗
PubMed1998

The cost-effectiveness of managed care regarding chronic medicine prescriptions in a selected medical scheme.

The purpose of the study was to examine the cost-effectiveness of managed care interventions with respect to prescriptions for chronic illness sufferers enrolled with a specific medical scheme. The illnesses included, were epilepsy, hypertension, diabetes and asthma. The managed care interventions applied were a primary discount; the use of preferred provider pharmacies, and drug utilization review. It was concluded that the managed care interventions resulted in some real cost savings.

Asthma↗
PubMedDate not supplied

Exploring the utility of automated drug alerts in home healthcare.

Computerized drug utilization review (DUR) can potentially reduce adverse drug events. We examined automated DUR for home healthcare patients with diabetes or hypertension. Sixty-eight percent of diabetes patients and 50.7% of hypertension patients triggered severe, moderate, or duplicative alerts. Among diabetes patients, 74.3% of duplicative alerts were trivial or inappropriate, compared with 3.9% among hypertension patients. Experts judged that 40.5% of high-risk diabetes patients and 53.6% of hypertension patients had alerts requiring nurse follow-up. Adequate follow-up was significantly lower for the former. The relationship between inappropriate alerts and poorer follow-up reinforces the need for more specific alert systems to focus clinicians' attention on clinically important alerts.

Adverse Drug Reaction Reporting Systems↗
PubMedDate not supplied

An opportunity for medication risk reduction, healthcare provider collaboration, and improved patient care: a retrospective analysis of osteoporosis management.

OBJECTIVES: The objectives of this study were to examine the degree to which long-term care providers are compliant with product labeling regarding administration of alendronate in patients with renal insufficiency and presence of, or predisposition to, upper gastrointestinal disorders; and to observe differences, if any, in prescribing patterns between alendronate and calcitonin-salmon nasal spray in skilled nursing facilities. STUDY DESIGN: We studied retrospectively analyzed patient charts, including medication histories and laboratory data. SETTING: Our study comprised 134 skilled nursing facilities from 21 states. PARTICIPANTS: We studied postmenopausal women, age > or =65 years, receiving either alendronate or calcitonin-salmon nasal spray for a minimum of 2 weeks. MEASUREMENTS: Consultant pharmacists reviewed resident charts submitted the following data for each resident: 2-week history of alendronate or calcitonin use, 2-week history of H2 receptor antagonist or proton pump inhibitor use, most recently documented serum creatinine, actual body weight, and date of birth. RESULTS: Of 905 subjects in the analysis, 38.5% (n = 348) did not have documentation of serum creatinine. Of the 267 alendronate patients for whom creatinine clearance could be calculated, more than half had renal insufficiencies of creatinine clearance <35 mL/min/1.73 m(2) (51.3%, n = 137). In addition, despite widespread information regarding caution in using alendronate in patients with upper gastrointestinal disorders, we found that 33.9% (n = 151) of all alendronate patients were concurrently receiving either H2 receptor antagonists or proton pump inhibitors. Although similar results were observed in the residents taking calcitonin, that agent has no precautions regarding its use in the renally impaired or in patients with gastrointestinal disorders. CONCLUSION: Data from this study indicate that long-term care clinicians might not be adequately differentiating patient profiles and safety criteria when initiating residents on osteoporosis pharmacotherapy, as evidenced by similar prescribing trends in both the alendronate and calcitonin groups. Given its package insert's statements regarding use of alendronate in the renally compromised, results from the alendronate group were particularly problematic as a result of the large number of residents with either insufficient renal function or undocumented serum creatinine. These data demonstrate that osteoporosis could be a disease state that should be more closely analyzed through drug utilization reviews and represent yet another opportunity for improved collaboration between medical directors and consultant pharmacists.

Aged↗