Drug-use Review Research Articles

Career pathways for pharmacists

Pharmacists continue to be in great demand to serve as our society's trusted professionals who provide oversight and expertise in the distribution of prescription and nonprescription drug products. At the same time, however, pharmacists have a diverse set of career paths open to them. Some examples of how pharmacists' skills are being used to improve the medication use process include careers in medication therapy management, pharmaceutical care, drug-use review, drug-use management, disease management, and pharmacy benefit management.

Identification of Inappropriate Drug Prescribing by Computerized, Retrospective DUR Screening in Korea

In Korea, the drug use process has changed significantly since the new pharmacy law was implemented in 2000, separating the prescribing and dispensing functions between physicians and pharmacists and mandating prospective drug use review (DUR) practice by pharmacists immediately before dispensing medications. However, a high prevalence of inappropriate prescribing has been suspected by the public, pharmacists, and health insurance managers, possibly due to suboptimal DUR practice by pharmacists. To assess overall patterns of drug usage and potential problems of inappropriate use in outpatient settings by analyzing prescription data that were electronically submitted to the national health insurance manager with a computerized DUR system and develop a computerized adjudication system model for drug claims. The national prescription drug claims data that were submitted electronically by pharmacies located in the northern part of Korea during 15 days in 2002 were retrospectively screened against the predetermined DUR standards of the selected criteria on drug dosage, duration of therapy, and drug interaction using the DUR screening system. The results of all the DUR conflicts were further validated manually by an expert panel and statistically analyzed to determine drug use patterns. Of 31,994,260 drugs prescribed, 3,325,760 (10.4%) items showed a conflict with at least one of the DUR standards. The average number of drugs prescribed on each prescription was 4.07, and even more troubling was the high incidence of under-dosing, over-dosing, and contraindicated drug prescribing. It is evident that inappropriate drug prescribing is very common in Korea; thus, a great deal of attention is urgently needed in the country with respect to proper prescribing and supportive interventions.

病院薬剤師における業務内容の分類法と定量的分析

The time spent by clinical pharmacists on various activities was measured using a multidimensional work-sampling method to identify their work activities and the staff requirements. This study was conducted over a 10-day period using, as study subjects, two clinical pharmacists working in the surgical wards of a hospital (50 beds each). To analyze the work activities, the hospital pharmacy work was carefully classified, categorized, defined and coded based on information obtain from pharmaceutical studies and interviews conducted during the study.During the study period, 9, 592 observations were collected. The results showed that the study subjects (clinical pharmacists) spent 78.6% of their time or about 6.3 hours per day performing clinical activities. The major work activities included the following : (1) giving instructions and consultations to patients (23.6%); (2) reviewing and assessing the patients' charts and performing drug-use reviews (21.4%); (3) sharing patient information with staff (15.4%); (4) managing drug information (9.9%). On average, a pharmacist provided service to 15.0 patients each day and spent 7.2 minutes with each patient providing inpatient-consultation services. The results showed time variations ranging from 1.0 to 38.5 minutes in the inpatient-consultation activities and a further study was required to investigate the relationship between the casual time variation and the patient's characteristics. In fact, the two pharmacists of this study were able to provide consultation services to only 76.9% of the inpatients in their wards.In conclusion, the results of this study revealed that hospital pharmacists had insufficient time to provide adequate clinical services to all patients. Therefore, staff requirements should be estimated based on the time required to be spent by a pharmacist on each patient while also considering variations in each patient's needs and characteristics.

Outcomes of prospective drug-use review of beta-agonist inhaler use in an elderly medicaid population

In 1990 Congress mandated that all state Medicaid programs implement both retrospective and prospective drug-use review (DUR). Nearly a decade later, implementation of prospective DUR (ProDUR) remains incomplete, and few of the implemented systems have been rigorously evaluated. This study was undertaken to analyze the impact of ProDUR screening of beta-agonist inhaler use in the Maryland Medicaid program from 1994 through 1996. The study used a pre/postcomparison series cohort design with data from Maryland, Georgia, and Iowa. Regression analysis was used to control for population differences between states in the year before the ProDUR intervention. The analysis used Medicaid and Medicare enrollment and claims data to select the study cohorts, assess exposure to the ProDUR intervention, develop patient risk profiles, and tabulate rates of adverse clinical outcomes for each subject. The study compared incidence rates for adverse outcomes for 2 1/2 years after implementation of the beta-agonist screens in Maryland, Georgia, and Iowa. Descriptive time plots and regression models were used to test the hypothesis that ProDUR screening reduces the incidence of adverse effects associated with misuse of beta-agonist inhalers. The study end points included 10 clinical outcomes related to therapeutic duplication and drug-drug interactions involving beta-agonist inhaler use by elderly individuals with chronic lung disease. No significant changes in the incidence of these outcomes could be linked to ProDur screening.

Disease management in the alternate-site health care setting.

The role of pharmacies that specialize in the treatment of specific chronic diseases in the alternate-site health care setting is discussed. The optimal use of medications through disease management programs can improve patient outcomes and lower overall health care costs. The increase in disease management programs has spawned the growth of disease-specific pharmacies in the home care and other alternate-site health care settings. These pharmacies usually operate from a single location or are regionalized operations that deliver pharmaceutical products to patients throughout the United States. The pharmacies employ clinicians who specialize in a particular disease. These clinicians conduct comprehensive patient education programs, drug-use review, and compliance monitoring. Disease management pharmacies focus on chronic, expensive diseases; costs related to inventory, equipment, and storage can be very high. Many disease management pharmacies are involved in preferred-distribution or closed-distribution arrangements with pharmaceutical manufacturers. Pharmacists involved in disease management programs routinely send compliance information about their patients to pharmaceutical companies, managed care organizations, or prescribing physicians. Disease management pharmacies act as advocates for patients with particular chronic diseases. Various foundations and patient advocacy and research groups have created their own disease management pharmacies. Disease management has also reached the community pharmacy practice setting. Pharmacies specializing in the treatment of specific chronic diseases in the alternate-site health care setting can improve health care and promote efficient use of health care dollars.

Tools, information sources, and methods used in deciding on drug availability in HMOs

The use and importance of specific decision-making tools, information sources, and drug-use management methods in determining drug availability and use in HMOs were studied. A questionnaire was sent to 303 randomly selected HMOs. Respondents were asked to rate their use of each of four formal decision-making tools and its relative importance, as well as the use and importance of eight information sources and 11 methods for managing drug availability and use, on a 5-point scale. The survey response rate was 28%. Approximately half of the respondents reported that their HMOs used decision analysis or multiattribute analysis in deciding on drug availability. If used, these tools were rated as very important. There were significant differences in levels of use by HMO type, membership size, and age. Journal articles and reference books were reported most often as information sources. Retrospective drug-use review was used very often and perceived to be very important in managing drug use. Other management methods were used only occasionally, but the importance placed on these tools when used ranged from moderately to very important. Older organizations used most of the management methods more often than did other HMOs. Decision analysis and multiattribute analysis were the most commonly used tools for deciding on which drugs to make available to HMO members, and reference books and journal articles were the most commonly used information sources. Retrospective and prospective drug-use reviews were the most commonly applied methods for managing HMO members' access to drugs.

Effect of including both physicians and pharmacists in an asthma drug-use review intervention

Effect of including both physicians and pharmacists in an asthma drug-use review intervention

Relational database for drug-use review of Tennessee Medicaid claims

The development of a relational database from Tennessee Medicaid files for the purpose of retrospective drug-use review (DUR) and application of the database for DUR of angiotensin-converting-enzyme inhibitors (ACEIs) are described. Computer queries were designed to create profiles of physicians' or pharmacies' experiences from claims data and other Medicaid data. Outlying patients (patients for whom at least one DUR criterion was unmet) were grouped according to their physicians or pharmacies. Thresholds for defining outlying physicians and pharmacies (i.e., those with more than a specified number of outlying patients) were based on the provider population instead of the patient population as a whole; aggregating patient outliers by provider allowed trends of inappropriate practices to be detected. As the threshold for outlying providers rose, the number of such providers fell, as did the number of outlying patients with whom they were associated. Stratification of the outliers by provider for specific drug-drug interactions and drug-disease complications afforded the option to set individual thresholds for outlying providers based on individual subsets; for example, for ACEIs, a threshold of greater than five patient outliers could be set for the criterion of no concurrent potassium supplements and a threshold of greater than three, for the criterion of no unmonitored concurrent lithium therapy. Tennessee patients formerly covered by Medicaid are now enrolled in managed care plans, and the flexibility of the database has allowed it to be modified accordingly. The relational database allows flexibility in the analysis of certain patterns of drug use. Such a database may be useful to other Medicaid programs that are converting to managed care models.

Basics of Managed Care Claims Processing: From Claims Payment to Outcomes Management

OBJECTIVE: Describe the evolution of prescription claims processing from claims payment systems designed in the 1970s to interactive point-of-service (POS) systems that enable pharmacists to conduct prospective drug-use review; and discuss current programs that link prescription databases with medical, hospital, laboratory, and other health care records; and explore the benefits and limitations of electronic point-of-service systems for providers, payers, and patients. DATA SOURCES: Not applicable. DATA EXTRACTION: Not applicable. DATA SYNTHESIS: Claims-processing systems have developed quickly from the completion of manual forms in the 1970s, to standardization of forms using the National Drug Code and the National Pharmacy Identification Code; to the real-time point-of-service (POS) systems of the 1990s that provide management functions. POS systems benefit the pharmacy, patient, and pharmacy benefit management company. The capability of performing prospective drug-use review is one of the most important advantages of POS systems. On-line systems also form the basis for measuring the outcomes produced by a particular pharmacy and for conducting outcomes research studies. CONCLUSION: Claims databases will be used more for research, patient case management, and evaluating the performance of pharmacists and other health care providers.

Pharmacy management company-negotiated contract for drug information services

University-based drug information services provided on a contractual basis to the pharmacies of a pharmacy management company are described. Allied Pharmacy Management, Inc. (APM), the manager of 34 institutional pharmacies, 3 community pharmacies, and 6 long-term-care and infusion therapy pharmacies, determined a need to contract for the services of a drug information center. Centers meeting basic criteria were invited to submit proposals. After careful research and negotiations, APM chose the University of Tennessee Drug Information Center for a one-year contract beginning in November 1992. Services provided under the contract include drug information consultations, formulary drug class reviews, new drug monographs, drug-use evaluation (DUE) criteria, literature reviews, and newsletters. Seven months after the contract went into effect, APM-affiliated pharmacy directors stated that they were either satisfied or very satisfied with the quality of the answers to drug information requests, the newsletters, and the drug monographs and agreed overwhelmingly that the contract should be renewed. The contract has been renewed for second and third years. During the first year, the drug information center answered 155 questions and took 121 hours to do so. In the second year there were 244 questions, requiring 161 hours. In year 1 there were 21 formulary class reviews, 6 newsletters, 5 new drug monographs, and 1 set of DUE criteria. There have been 20-25 literature searches during each contract year. The drug information services provided by a university-based drug information center under contract with a pharmacy management company satisfied the directors of the affiliated pharmacies.

Pre-OBRA '90 Medicaid Survey: How Community Pharmacy Practice Is Changing: Full compliance with the federal counseling law will bring major changes to Virginia pharmacies, but such change may come slowly.

Medicaid pharmacy providers in Virginia were surveyed to estimate the potential impact of the Omnibus Budget Reconciliation Act of 1990, which mandated prospective drug use review (DUR) beginning January 1, 1993. The data measure which DUR activities were being performed by pharmacists before the law took effect, and the survey compares and contrasts these data with the activities mandated by full compliance with the law. Many respondents already perform several of the required DUR activities, and nearly all agree that full compliance requires more time to process each prescription order. Barriers to full compliance include lack of time to counsel patients adequately, lack of patient-specific information, and no compensation for offering clinical/cognitive services.

Omnibus Budget Reconciliation Act of 1990 and Voluntarism: Logistic Regression Analysis of Pharmacist Responsibility

To examine the relationship between pharmacists' willingness to assume further professional responsibilities, as measured by attitudes to the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) requirements, and their attitudes toward voluntarism as their responsibility to society and their level of interest in their jobs. A survey was distributed to a convenience sample of 443 pharmacists who were asked to indicate their responses on a number of items. Surveys were distributed to participants in an annual pharmacy continuing education program. The response rate was 65 percent with completed surveys from 290 Florida pharmacists who were typically male (73 percent) and practicing in the community setting (39 percent) for over 25 years (33 percent). Questions were aimed at gathering the following information: (1) demographics; (2) attitudes concerning the benefits of the three OBRA '90 requirements: patient counseling, prospective drug-use review (DUR), and information recording; (3) attitudes toward voluntarism; and (4) job interest. Pharmacists tended to agree that all three of the OBRA '90 mandates will be beneficial. Fifty-six percent favored the prospective DUR requirements, while 68 percent favored the patient counseling requirements and 66 percent favored the information-recording requirements. Logistic regression analysis showed that unit increases in scaled responses, indicating more favorable attitudes toward believing that voluntarism was one's responsibility, increased the odds of favoring counseling by 38.7 percent and information recording by 32.4 percent. A similar directional relationship was found for the DUR requirement. Job interest did not add to the predictive ability of the variables already in the models. This study suggests a possible association between pharmacists' attitudes toward social responsibility and their acceptance of expanded professional responsibility.

Pharmacists' Reactions to the Wisconsin Medicaid Drug-use Review Program

Pharmacists' reactions to inquiries on Medicaid drug-use review (DUR) and how the information supplied by such inquiries influenced pharmacists' interactions with physicians were studied. A questionnaire was mailed in September 1991 to all 137 pharmacies that had been contacted in 1989 by the Wisconsin Medicaid DUR program about potentially inappropriate use of histamine H2-receptor antagonists. The survey sought to determine whether pharmacists used information in the DUR letters and, if so, how. A section for consultants was included to identify possible differences in responses between consultant and nonconsultant pharmacists. A response was received from 96 of the 137 pharmacies contacted. Pharmacists reported that the issues raised by the DUR letter frequently were discussed with the prescriber. Most respondents attempted to make changes in drug therapy based on the information supplied in the DUR letter. Consultant pharmacists were less likely than nonconsultants to refer to the DUR letter but were more likely to consider inclusion of copies of references to the medical literature helpful, to contact the prescriber in writing, to discuss alternative therapies or discontinuation of therapy, and to suggest patient-monitoring activities. Although consultants and nonconsultants tend to use DUR information in different ways, DUR does offer helpful information that is used by Wisconsin pharmacists in making drug therapy recommendations to prescribers.

Impact of drug usage review on drug utilisation.

Drug use review (DUR) programmes have been a component of efforts to improve prescribing practices in both the institutional and ambulatory care settings in various areas of the world. DUR provides the mechanism for developing standards, assessing current therapy, and implementing a specific intervention followed by reassessment of drug utilisation. A number of interventions aimed at improving drug prescribing practices have been included as components of the DUR process. At this time, face-to-face interaction with the prescriber has been shown to be the most effective intervention. However, DUR interventions have rarely been subjected to quality pharmacoeconomic evaluation. There is a need for future research to evaluate the effects of DUR programmes on overall healthcare outcomes.

Presentation of Drug Prescribing Guidelines and Physician Response

Most Medicaid Drug Use Review (DUR) Programs disseminate prescribing practice guidelines by providing written reviews to physicians about specific prescribing practices that do not follow established criteria and inviting their comment. This study reviewed physicians' written responses to explore relationships between DUR communications and the degree to which these communications affect awareness of prescribing issues, increase knowledge, change erroneous beliefs, and generate intentions to apply the information appropriately. The form, content, and effective tone for all responses received in 1990 regarding five different drug therapy issues (N = 240) was recorded. Response rates, comprehension, counterarguments, and prescribing intentions varied by drug therapy issue. Attention to the communication process could improve the dissemination of prescribing practice guidelines by DUR Programs.

DUE Software Highlights Therapeutic Issues: Drug use evaluation systems concurrently review prescribing criteria and patient medication history to identify potential drug therapy problems.

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 identifles 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.

Principles of drug-use review approved by APhA, AMA, and PMA

Principles of drug-use review approved by APhA, AMA, and PMA

Use of antimicrobial drugs in adults before and after removal of a restriction policy

The effects on the quantity and quality of antimicrobial drug use of removing an antimicrobial restriction policy are reported. Monthly totals for the number of courses of antimicrobial therapy and expenditures based on grams used were obtained from pharmacy records on adult inpatients for a portion (July-December 1987) of the restriction policy term and for the six months (July-December 1988) immediately after the policy ended. Data were obtained for nine restricted drugs and for three that were never restricted. Retrospective drug-use reviews were conducted for ceftazidime and imipenem-cilastatin. For the restricted agents, the total number of courses of therapy increased by 158% after the restriction policy was removed, and total expenditures increased by 103%. There were no significant changes in the number of courses of therapy or cost for the unrestricted antimicrobials. In the postrestriction period, ceftazidime and imipenem-cilastatin were used more often in patients who were less critically ill. Inappropriate use of imipenem-cilastatin occurred significantly more often after the restrictions were removed. Other factors potentially affecting the use of antimicrobials, such as patient age and the incidence of nosocomial infections, did not differ substantially between the two periods. The removal of an antimicrobial restriction policy resulted in increased use of and higher expenditures for previously restricted agents, as well as an increase in the inappropriate use of at least one agent.

Drug-use review program for concurrent histamine H2-receptor antagonist-sucralfate therapy

The effect of drug-use review on concomitant histamine H2-receptor antagonist-sucralfate therapy at a 600-bed, university-affiliated Veterans Affairs medical center was studied. In an effort to curtail the concomitant use of H2-antagonist plus sucralfate therapy, the department of pharmacy, in conjunction with the gastroenterology service, developed and introduced criteria for the appropriate use of combination therapy. The extent of prescribing of concomitant histamine H2-receptor antagonist-sucralfate therapy before and after implementation of criteria-based guidelines and the appropriateness of current H2-receptor antagonist-sucralfate combination therapy, based on the guidelines, were assessed. The effectiveness of the intervention process was evaluated, and cost savings associated with intervention were calculated. After intervention, the number of treatment courses of histamine H2-receptor antagonist-sucralfate combination therapy decreased by 30%. However, of the 109 evaluable postintervention combination treatment courses, only one complied with both the indication and the duration of treatment criteria. This review of prescribing patterns and the implementation of criteria-based guidelines proved an effective means of reducing inappropriate combination therapy and resulted in annual cost savings of $25,000.

Impact of a Drug-Use Review Program Intervention on Prescribing after Publication of a Randomized Clinical Trial

The effect of a drug-use review (DUR) program intervention on physician prescribing after the results of a randomized clinical trial were published was studied. A Veterans Administration (VA) cooperative study published in June 1986 showed that congestive heart failure (CHF) patients who had hydralazine and isosorbide added to their drug therapy had less mortality than patients given digoxin and diuretics with or without prazosin. Physicians with at least one CHF patient who was receiving the less effective therapy were randomly assigned to intervention and control groups. In September 1986, intervention-group physicians (n = 288) were mailed a letter and questionnaire from the DUR program coordinator, the journal article, and a drug history profile of a CHF patient who might benefit from the information. Control physicians received no mailing. The questionnaire asked whether the physicians already knew about the VA study, intended to alter their prescribing, and could identify factors that would affect their decision. Two thirds of intervention-group physicians were already aware of the VA study. One third indicated that they intended to alter drug therapy based on the study results; factors significantly associated with the intent to adopt a change were physician training and experience, comments by peers, new drug availability, and the size of the reduction in mortality. During four months after the intervention, only 5 physicians in the two groups switched their patients to both hydralazine and isosorbide (full change); 23 switched them to at least one of the drugs or discontinued prazosin (partial change). There was no significant difference in the number of full or partial changes between groups.(ABSTRACT TRUNCATED AT 250 WORDS)