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PubMedDate not supplied

Retrospective drug utilization review: incidence of clinically relevant potential drug-drug interactions in a large ambulatory population.

OBJECTIVE: To determine the incidence of clinically relevant potential drug-drug interactions (DDIs) in a large population of ambulatory patients utilizing a computerized, retrospective drug utilization review (DUR) program followed by clinical pharmacist audit. METHODS: The drug claims database included approximately 2.9 million patients with more than 30 million prescriptions dispensed in the 12-month period from September 2001 through August 2002. Cases were identified by a computerized, retrospective DUR program with embedded triggers to detect 69 prespecified potentially serious DDIs, with "serious" defined as an interaction that would likely require a change in therapy or use of additional clinical or laboratory monitoring. Two types of automated, computerized assessments were conducted: the first simply detected coprescribed drug pairs, and the second assessment used more sophisticated filters to reduce false positive alerts for coprescribed drug pairs. Clinical pharmacist audit then determined the final incidence of clinically relevant warnings; in this audit, coprescribed drug pairs were defined as clinically relevant if they could cause potentially serious DDIs. RESULTS: Eighteen drug pairs had insufficient cases for inclusion, leaving 51 drug pairs for evaluation. A total of 244,703 cases of potential DDIs were identified (0.8% of total prescription claims) by simple automated screens. More sophisticated DDI filters reduced the 244,703 potential DDIs by 70.8%, to a total of 65,544 pairs (0.2% of total prescription claims). Clinical pharmacist review reduced the number of potential DDIs by an additional 80.6%, to 12,722 drug pairs (0.04% of total prescription claims) deemed clinically relevant. The combination of sophisticated DDI filters and clinical pharmacist review reduced the incidence of potentially serious DDIs by 94.3%. CONCLUSION: The incidence of potentially serious DDIs is relatively low (less than 1%) among ambulatory patients; however, the incidence depends on the method of case finding. Retrospective DUR programs, especially those with additional automated filters or that utilize additional pharmacist review, appear to be important screening tools in determining true rates of coprescribed drug pairs that can lead to potentially serious DDIs.

Ambulatory Care↗
PubMed1989

Marketing utilization review services.

This article, the first of two, explains how health-care providers can increase their market share and profit margins and improve quality of care by marketing utilization review services. Selling these services to employers or other potential buyers requires reliable data and an understanding of the needs of various players in the marketplace.

Commerce↗
PubMed1981

Diagnostic services utilization review at a university medical center.

The rational provision of diagnostic services is important in maintaining health care quality and controlling costs. Establishing a successful diagnostic services utilization review committee requires substantial commitment from the hospital and the medical staff.

Diagnostic Services↗
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↗
PubMedDate not supplied

Drug utilization review of concomitant use of specific serotonin reuptake inhibitors or clomipramine with antianxiety/sleep medications.

Side effects of some antidepressants include anxiety and insomnia. A retrospective drug utilization review was conducted to determine the amount of concurrent use of an antidepressant with medication that may counteract these side effects. Texas Medicaid claims data for 1993 included more than 30,000 patients receiving a specific serotonin reuptake inhibitor (SSRI) or clomipramine. A total of 35.0% of these patients were also taking a medication that could be used to relieve anxiety or induce sleep, and 15.2% of the total were receiving once-daily dosing of the latter type of medication. Concomitant use of SSRIs or clomipramine with trazodone occurred in 7.7% of the patients.

Anti-Anxiety Agents↗
PubMed1976

A computer package to facilitate compliance with utilization review requirements.

The Cumberland County CMHC in Fayetteville, North Carolina, developed a series of computer programs to produce the information that is required by area regional utilization review committees. There is a total of eight programs. The first establishes a master file and prints out all the information that has been gathered on all the clients. The other seven programs retrieve various portions of the data stored in the master file. The system does not require elaborate in-house computer equipment. It is easy to operate and benefits clients by enabling clinical staff to spend less time on documentation and more time on direct treatment.

Community Mental Health Services↗
PubMedDate not supplied

A national perspective on UR (utilization review).

Quality of care is the responsibility of each and every attending physician. There are many definitions of quality, none of which encompasses the universe of medical practice. Care that is neither medically necessary nor appropriate can never be considered good, no matter who renders it or how good the outcome. It is upon these premises that utilization review firms focus.

Concurrent Review↗
PubMed1989

Focused utilization review strategies.

Researchers from the Michigan Health Care Education and Research Foundation, a research affiliate of Blue Cross and Blue Shield of Michigan, compared three focused utilization review (UR) strategies to determine which method most effectively and efficiently identifies nonacute inpatient hospital admissions. Intensity, Severity, Discharge-Appropriateness (ISD-A) criteria were used to identify nonacute admissions in 8,973 cases in 73 Michigan hospitals. Significant proportions of nonacute admissions were found in medical, psychiatric, and substance abuse cases; surgical admissions had the lowest rates. Strategies involving the concentration ratio were most effective at indicating potential efficiency gains. Focused UR on Diagnosis-Related Groups (DRGs) with nonacute rates greater than 15% captured 41% of admissions and accounted for 85% of nonacute admissions, 85% of nonacute days, and 80% of potential dollar savings. This suggests that UR efforts focused primarily on DRGs with high nonacute rates would significantly improve the efficiency and effectiveness of the overall UR process.

Acute Disease↗
PubMed1977

Drug utilization review in an HMO. I. Introduction and examples of methodology.

An experimental drug utilization review program was developed for a health maintenance organization (HMO). The objectives of the program were to develop and implement an ongoing mechanism for reviewing drug use using criteria based on the scientific literature, and to evaluate the effect of the drug use review program on physician precribing patterns. Seven therapeutic categories of drugs, accounting for over 65 per cent of prescribing, were selected and criteria developed for their use. The drug use review prcedure is described briefly. The evaluation of the drug use review program is based on a comparison of rates of prescription use for specific therapeutic categories before and after the criteria were ceveloped and approved. As an example, data for the antihistamine therapeutic category are presented. Criteria for prescribing antihistamines suggested restricting use of combination cold preparations and refraiming from antihistamine use in viral upper respiratory tract infections. After the criteria were adopted, prescribing of antihistamines for viral URIs declined, particularly in pediatrics. In general, prescribing of combination antihistamine preparations did not change; where one combination preparation was deleted from the formulary, prescribers appeared to substitute another combination preparation.

Adolescent↗
PubMed2000

Utilization review: a practical approach for physicians.

Rhode Island has rules and regulations for UR, as well as an appeals process. When the appeals process is used, it is more often than not successful. (Table 1) If questions arise concerning the UR Act, the UR process, the appeals process, the rights of patients, physicians, and reviewers, or the authority of the HEALTH, please contact OMCR. For a copy of the Rules and Regulations for the Utilization Review of Health Care Services (R23-17.12-1-UR), please write: Rhode Island Department of Health Office of Managed Care Regulation 3 Capitol Hill Cannon Building, Room 410 Providence, RI 02908.

Certification↗
PubMed2000

Systemwide effects of Medicaid retrospective drug utilization review programs.

Aggregate pooled cross-sectional and time-series annual state data for 1985 to 1992 were used to estimate the systemwide effects of retrospective drug utilization review programs (Retro-DUR) on Medicaid drug and nondrug outcomes. The results provide evidence that these programs produce significant cost savings in the drug budget without spillover effects (positive or negative) in other nondrug budgets within the Medicaid system. We also examine the influence of restricted formularies in this post-Retro-DUR era on drug and nondrug budgets in the Medicaid system; we find significant cost savings in the former but positive spillover effects in the latter.

California↗
PubMed1989

Development of an outpatient utilization review program.

Usage of outpatient services has reached an all time high. Insurers and employers seek means to monitor the escalating costs for providing ambulatory care. This article offers insight about the objectives of managed care groups and what they are looking for in their outpatient utilization review endeavors.

Ambulatory Care↗
PubMed1978

Aggressive utilization review shortens stays, lowers costs.

Reducing the number of overextended hospital stays no longer presents a problem at Framingham (MA) Union Hospital. Through the use of aggressive techniques designed by its utilization review committee, the hospital consistently has a better average length of stay by diagnosis than its peers in its geographic area. The hospital also has been able to avoid having an adversary relationship with its medical staff and has been successful in increasing patient awareness of the impact of federal regulations and cost constraints on hospitalization.

Costs and Cost Analysis↗
PubMed1990

Drug utilization review in a teaching hospital: experience with vancomycin.

A prospective, two-phase, drug utilization review (DUR) was performed at the Royal Adelaide Hospital (RAH) to determine the extent and pattern of vancomycin use. For all patients commencing oral or parenteral vancomycin, treatment indication, route of administration, duration of therapy, results of culture and sensitivity tests, adverse drug reactions and results of therapeutic drug level monitoring were recorded. Vancomycin courses were classified as being for therapy or prophylaxis and compared with predetermined audit criteria to assess appropriateness of use. During the 8 week initial phase, data on 62 treatment courses in 59 patients were recorded, 50% for therapy and 50% for prophylaxis. Sixty four percent were classified as inappropriate, occurring in 32% of therapeutic courses and 97% of those for prophylaxis. During the 10 week re-evaluation, conducted 10 months later, data for 43 treatment courses in 43 patients were reviewed, 42% for therapy and 58% for prophylaxis. Sixty five percent were inappropriate occurring in 17% of therapeutic courses and 100% of the prophylactic courses. When compared with the initial phase, the re-evaluation demonstrated a decrease in the empirical use of vancomycin in the combination treatment of neutropaenic fever and also in the duration of vancomycin use for surgical prophylaxis. During both study phases, criteria contraventions were mostly due to inappropriate indication or duration of therapy. The cost of inappropriate vancomycin use was reduced by over 50% between survey phases, from $Aus11,500 or 55% of total vancomycin cost during the initial phase to $Aus3,600 or 25.7% during the re-evaluation. The most effective of the remedial strategies implemented after the initial phase was direct consultation with prescriber groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

The use of utilization review nurses to decrease reimbursement denials.

Since the implementation of HCFA forms 484, 486, and 487, the home health industry has experienced a dramatic increase in the rate of reimbursement denials. One agency responded by developing a utilization review program that has successfully reduced technical and medical denials.

Home Care Services↗
PubMed1987

Intravenous metronidazole: a drug utilization review in a community hospital.

The recent release, relatively high cost and extensive usage of intravenous metronidazole, in a 690-bed community hospital, prompted a drug utilization review of this antimicrobial agent. The review was retrospective and occurred over the period of October 25, 1984, to April 10, 1985. All patients started on intravenous metronidazole were assessed. The quality of use of intravenous metronidazole was determined on the basis of pre-established criteria, which were developed from the literature and in consultation with the hospital's Medical Microbiologist. These criteria were approved by a peer review committee of medical staff. Drug utilization was assessed as either appropriate or inappropriate. Appropriate therapy implied compliance with all of the criteria for appropriate intravenous metronidazole use with respect to indication, dose, dosage frequency, timing of perioperative prophylaxis, duration of use, and concurrent antimicrobial drug use, when metronidazole was prescribed for prophylaxis, empiric treatment or treatment of a documented infection (documented treatment). Inappropriate use implied non-compliance with one or more of the criteria. Fifty-four courses of intravenous metronidazole in fifty in-patients were reviewed. Of the total usage of intravenous metronidazole, 50%, was judged to be inappropriate. Although the Surgical Services accounted for 56% of the total usage, only 13% of the total intravenous metronidazole use was for surgical prophylaxis. Of these cases, 57% were inappropriate. Seventy percent of the total intravenous metronidazole use was for empiric treatment; 53% of these cases were considered inappropriate. The reasons cited most frequently for inappropriate prophylactic or empiric use were inappropriate indication and inappropriate dosage frequency.(ABSTRACT TRUNCATED AT 250 WORDS)

Costs and Cost Analysis↗
PubMedDate not supplied

A test of mental health parity: comparisons of outcomes of hospital concurrent utilization review.

The Mental Health Parity Act of 1996 had as its goal the equity of coverage of mental health care and physical health care. The purpose of this study was to examine the outcomes of hospital concurrent utilization review as a measure of the progress toward the equity goal. The study examined 4 years of denials of certification for reimbursement by payers of inpatient care (1998-2001). Psychiatry was first compared to clinical services with a like number of annual admissions and then compared to clinical services with a like number of concurrent reviews. For each year, psychiatry had the highest numbers of cases denied and patient days denied. The most frequent reason for a psychiatric denial was that the inpatient benefit level had been exceeded. There was only one instance, in 4 years, when this reason (benefit limit exceeded) was given for a patient with a physical illness. This study provides evidence of the current inequity of reimbursement for treatment of mental illness.

Hospitalization↗
PubMed1989

Does utilization review reduce unnecessary hospital care and contain costs?

Research indicates that approximately one in five hospital admissions is unnecessary or inappropriate, based on accepted clinical criteria. Various cost-containment approaches have been initiated to reduce unnecessary hospital care. Among these approaches, hospital utilization review (UR) has shown promise as a cost-containment strategy. Although third party payers are increasingly relying on UR and similar approaches to contain health care expenditures, little is known about the effects of these efforts. This study analyzes insurance claims data on 223 insured groups for 1984 through 1986 to determine the effects of a UR program instituted by a commercial insurance company. It was found that UR had a significant negative effect on both utilization and expenditures, even after controlling for a large number of factors. Specifically, UR reduced admissions by 13%, inpatient days by 11%, expenditures on routine hospital inpatient services by 7%, expenditures on hospital ancillary services by 9%, and total medical expenditures by 6%. Even though UR reduced the level of utilization and expenditures, it did not appear to influence the rate of change in these areas over time. These findings suggest that hospital UR programs can reduce utilization and expenditures and generate cost savings, thereby helping to improve the efficiency of medical care resources consumption.

Cost Control↗