Drug Utilization Review Program Research Articles

Effect of nationwide concurrent drug utilization review program on drug-drug interactions and related health outcome.

A computerized drug utilization review (DUR) program has provided physicians and pharmacists with alerts on drug-drug interactions (DDIs), drug-age precautions and therapeutic duplication in Korea since 2010. The purpose of this study was to evaluate the impact of the DUR program on health outcomes associated with DDIs. An uncontrolled before-after study was performed to investigate the impact of the nationwide DUR program on DDIs and related health outcomes. The study population consisted of people who used two types of DDI pairs before DUR implementation (from January 2009 to December 2010) and post-DUR implementation (from January 2012 to December 2013); (i) benzodiazepines with concurrent use of metabolic enzyme inhibitors and (ii) QTc (heart-rate corrected QT interval) prolongation agents. The main outcome measures were all-cause and cause-specific hospitalization admissions or emergency department (ED) visits. This study included 107 874 people who used benzodiazepines with enzyme inhibitors and 8489 who received co-medication of QTc prolongation agents. For patients receiving a combination of benzodiazepines and enzyme inhibitors, both all-cause hospitalization and cause-specific hospitalization decreased after DUR implementation, from 43.2% to 41.7% and from 4.6% to 4.5% (adjusted odds ratio [OR] = 0.96; 95% confidence interval (CI), 0.93-0.98; OR = 0.89, 95% CI = 0.84-0.99, respectively). For patients receiving co-medication of QTc prolongation agents, all-cause hospitalization (54.2%) was lower than before (54.9%) (OR = 0.87, 95% CI = 0.79-0.96), but no significant change was found for cause-specific hospitalization and ED visits. Implementation of a DUR program may reduce the adverse health outcomes posed by DDIs in patients on combination of benzodiazepines and enzyme inhibitors potentially QTc-prolongation agents.

Potentially Inappropriate Prescriptions to Older Patients in Emergency Departments in South Korea: A Retrospective Study

PurposeThe purpose of this study was to evaluate the incidence of the administration of potentially inappropriate medications (PIMs) and the potential drug–drug interactions (pDDIs) in older patients in emergency departments (EDs) over a 12-month period and to identify the factors associated with the administration of PIMs.Patients and MethodsThis retrospective study was conducted using the electronic medical records from two university-affiliated teaching hospitals in South Korea. ED visit cases of patients aged 65 and older from January 1, 2013, to December 31, 2013, were included in the analysis. Among the medications administered in ED, PIMs or pDDIs were identified using a drug utilization review program available in Korea.ResultsDuring the study period, a total of 13,002 ED visit cases were reported from 10,686 patients. The proportion of ED visit cases with any PIM was 79.2% and the average number of PIMs was 2.7 (range, 1–17). The most commonly administered PIMs that were contraindicated or should have been used with caution were ketorolac (41.3%) and metoclopramide (10.3%), respectively. Multivariate regression analysis indicated that female patients (p = 0.012), patients with more than six drugs in the ED (p < 0.001), and visits longer than 300 minutes (p = 0.026) were significantly associated with PIM administration in the ED. Potential DDIs between the medications administered in EDs were observed in 20.5% of total visit cases, with ketorolac being the most frequently reported drug in contraindicated drug combinations.ConclusionThis study demonstrated a high incidence of the administration of PIMs and medications with pDDIs in older patients in EDs and revealed the characteristics that are significantly associated with an increased risk of PIM administration. Healthcare providers in EDs should consider the risk of administering PIMs or medications with pDDIs, especially when treating older patients.

Impact of a nationwide prospective drug utilization review program to improve prescribing safety of potentially inappropriate medications in older adults: An interrupted time series with segmented regression analysis.

A nationwide prospective drug utilization review (DUR) for potentially inappropriate medications (PIMs) in older adults was implemented in October 2015 in South Korea. We aimed to evaluate the effects of the DUR on reducing PIMs, in comparison with the PIMs defined using the Beers criteria that were not included in the DUR. We divided the study period into a pre- and post-DUR period. The monthly percentage of patients or prescriptions with at least one PIM in the DUR or defined by the Beers criteria was calculated using national health insurance data. We evaluated the effect of the DUR on the prevalence of PIM use in older adults using an interrupted time series with segmented regression analysis. The prevalence of older adults prescribed PIMs in the DUR decreased by 0.49% (95% confidence interval (CI) [-0.60, -0.37]) based on patient-based measures and, by 0.41% (95% CI [-0.58, -0.23]) based on prescription-based measure, immediately after DUR implementation. However, there were no statistically significant changes in trend. Further, the prevalence of PIMs based on the Beers criteria had no statistically significant changes in terms of either level or trend. After 12 months of DUR, there was a reduction of 11.5% (95% CI [2.6 20.4]) relative to the PIMs in Beers. The implementation of a nationwide prospective DUR lowered the prescription of PIMs for older adults. On the other hand, PIMs that were not included were unchanged. Thus, it is worth considering expanding the DUR list to improve prescribing safety.

Impact of a retrospective drug utilization review program on changing opioid prescribing behavior

The VA system is the largest single provider of healthcare in the United States and to individuals infected with HIV specifically. High quality medication management is particularly important since HIV is a chronic infectious condition which requires taking multiple medications with strict requirements for adherence to medication regimens. Veterans Administration (VA) patients are required to obtain all chronic medications using the VA mail-order pharmacy system.Drawing on Donabedian's Quality Improvement framework, this study sought to examine experiences that Veterans with HIV have with the Veterans Administration medication mail-order system, and to explore opportunities for quality improvement.A sequential, explanatory mixed-methods design was used to interview Veterans receiving care at a Midwestern Veterans Administration Hospital using a mail-order experience survey followed by in-depth interviews. All 57 Veterans, out of 72, who were successfully contacted consented to participate.Overall, Veterans evaluated the mail-order service positively and valued the accuracy (correct medication delivery). However, a notable problem emerged with respect to assuring access to HIV medications with about half (47%) indicating running out of HIV medication. Respondents identified structural issues with respect to days covered by mailed medications (90 versus current 30 days) and process issues with scheduling new refills. Veterans also indicated the information sheets were too long, complex and not helpful for their queries. Patients were open to pharmacists playing an active role during clinic visits and felt this would help manage their conditions better.Veterans generally reported that the VA Mail-order service was of high quality. However, some findings indicate there are opportunities to improve this service to be more patient-centered particularly for vulnerable HIV patients.

Evaluation of preventable adverse drug reactions by implementation of the nationwide network of prospective drug utilization review program in Korea

BackgroundA prospective Drug Utilization Review (DUR) program has been implemented in Korea to improve the quality and safety of medication use.ObjectiveTo evaluate the influence of the DUR program in reducing incidence of preventable adverse drug reactions (pADRs).MethodsThis study was performed using administrative data from the Health Insurance Review and Assessment Service (HIRA). The claims data for all adult patients with adverse drug events (ADE)-related diagnoses from 2009 to 2014 were obtained. Incidence rates of first-time and repeat pADRs prior to and after DUR program implementation were evaluated. Quarterly trends in incidence rates of overall ADE, allergic reactions, and ADRs were analyzed.ResultsData extraction covering the period from 2009 to 2014 led to the identification of 3,927,662 records. First-time pADR rates decreased gradually after implementation of the DUR program (change in slope: -0.016, p = 0.02). The program had a similar influence on repeat pADR rates (change in slope: -0.006, p≤0.01). The program did not decrease rates of first-time or repeat allergic reactions (change in slope: 0.018, p = 0.07 and 0.003, p = 0.04, respectively). In the cohort aged ≤65 years, first-time pADR rate reduction was significant (28.2% [27.1–29.3] in ≤18 years, and 19.8% [18.1–21.5] in 19–64 years). In contrast, first-time pADR rate was increased by 0.6% [-0.7–1.9] in patients ≥65 years.ConclusionImplementation of the prospective DUR program effectively reduced the number of pADRs. In the future, to reduce non-preventable ADRs such as allergic reactions, provision of clinical information including allergy history should be added to the DUR program.

Pediatric fluoroquinolone prescription in South Korea before and after a regulatory intervention: A nationwide study, 2007-2015

ObjectiveTo investigate the impact of national implementation of age restriction on fluoroquinolone prescription in children and adolescents.MethodsData collected from the database of Health Insurance Review and Assessment Service in South Korea, a national health insurance system to analyze fluoroquinolone prescribing practice in children and adolescents younger than 18 years, between 2007 and 2015. The age restriction was implemented in December 2009. The annual prescription rate of FQ per 100,000 person-years was calculated and an autoregressive model was used to predict the prescription pattern if an intervention had not occurred.ResultsA total of 505,859 children received systemic fluoroquinolone during the study period—297,054 ciprofloxacin, and 208,805 levofloxacin. After implementation of the drug utilization review program, the annual prescription rate for ciprofloxacin declined by 97.5% (from 840 to 21 per 100,000 person-years, P < 0.001), and for levofloxacin by 96.4% (from 598 to 11 per 100,000 person-years, P < 0.001). The decline was more dramatic in the outpatient setting than in the inpatient setting for both drugs.ConclusionThe dramatic and sustained decline in prescription number and change in prescription pattern after the regulatory action suggests that the implementation under drug utilization review program was successful in controlling excessive and inappropriate use of fluoroquinolones in children, possibly guiding towards more judicious and selective prescription behavior.

MONITORING OF PRESCRIPTION PATTERN OF ANTIMICROBIAL AGENTS IN MEDICINE DEPARTMENT OF A TERTIARY CARE HOSPITAL

Drug utilization review (DUR) programs are being conducted with the aim of improving the appropriateness of prescriptions. DURs have traditionally focused on drugs with frequent side - effects, high price tags or complicated dosing regimens. The main objective of the present study was to evaluate the antibiotic utilization pattern of antimicrobial agents and then to assess the prescriptions by the WHO prescribing indicators. This prospective and descr iptive study was carried out in the medicine department of Guwahati Medical College & Hospital, Guwahati, India from Feb. 2015 to Dec. 2015.The data obtained was represented as mean ± SEM and percentages, as applicable. An appropriate statistical test (chi square test) was used for determining association between variable. The results are calculated from 425 patients’ data. Out of 672 medicines, 500(74.4%) medicines were prescribed from National Essential Medicine List (NEML) 2015.There was a good tendency of prescribing by generic name. Use of injection was very high and percentage encounter with an injection prescribed was 92 % (391 cases).Ceftriaxone was the most frequently pres cribed medicine (217 cases) followed by metronidazole (65 cases). The physicia ns prescribing habit was the main factor that directly influences the prescribing patterning.

Using pharmacy quality measures in Medicaid drug utilization review programs

Drug–drug interactions (DDIs) are a significant cause for adverse drug events (ADEs). DDIs are often predictable and preventable, but their prevention and management require systematic service development. Most DDI studies focus on interaction rates in hospitalized patients. Less is known of DDIs in outpatients, particularly how community pharmacists could contribute to DDI management by applying their surveillance systems for identifying high-risk medications.The study was related to the implementation of the first online DDI surveillance system in Finnish community pharmacies. The goal was to demonstrate how community pharmacies can utilize their prospective surveillance system 1) for identifying high risk medications causing potential DDIs in outpatients, 2) for collaborative service development with local physicians, and 3) for academic risk management research purposes.All DDI alerts given by the online surveillance system were collected during a one-month period in 16 out of 17 University Pharmacy outlets in Finland, covering approximately 10% of the national outpatient prescription volume. The surveillance system was based on the FASS database, which categorizes DDIs into four classes (A–D) according to their clinical significance.Potential drug–drug DDIs were analyzed for 276,891 dispensed community pharmacy prescriptions. Potential DDIs were associated with 10.8%, or 31,110 of these prescriptions. Clinically significant interaction alerts categorized as FASS classes D (most severe, should be avoided) and C (clinically significant but controllable) were associated with 0.5% and 7.0% of the prescriptions, respectively.Methotrexate and warfarin had the highest risk of causing potentially serious (class D) interactions. These interaction alerts were most frequently between methotrexate and NSAIDs and warfarin and NSAIDs. In general, NSAIDs were the most commonly interacting drugs in this study.This study demonstrates that community pharmacies can actively contribute to DDI risk management and systematically use their surveillance systems for identifying patients having clinically significant DDIs. The findings also indicate that the majority of potentially serious interactions in outpatients involve a limited number of drugs, particularly NSAIDs, warfarin and methotrexate. Further research should focus on community pharmacists' involvement in DDI risk management in collaboration with local health care providers.

National Rules for Drug-Drug Interactions: Are They Appropriate for Tertiary Hospitals?

The application of appropriate rules for drug–drug interactions (DDIs) could substantially reduce the number of adverse drug events. However, current implementations of such rules in tertiary hospitals are problematic as physicians are receiving too many alerts, causing high override rates and alert fatigue. We investigated the potential impact of Korean national DDI rules in a drug utilization review program in terms of their severity coverage and the clinical efficiency of how physicians respond to them. Using lists of high-priority DDIs developed with the support of the U.S. government, we evaluated 706 contraindicated DDI pairs released in May 2015. We evaluated clinical log data from one tertiary hospital and prescription data from two other tertiary hospitals. The measured parameters were national DDI rule coverage for high-priority DDIs, alert override rate, and number of prescription pairs. The coverage rates of national DDI rules were 80% and 3.0% at the class and drug levels, respectively. The analysis of the system log data showed an overall override rate of 79.6%. Only 0.3% of all of the alerts (n = 66) were high-priority DDI rules. These showed a lower override rate of 51.5%, which was much lower than for the overall DDI rules. We also found 342 and 80 unmatched high-priority DDI pairs which were absent in national rules in inpatient orders from the other two hospitals. The national DDI rules are not complete in terms of their coverage of severe DDIs. They also lack clinical efficiency in tertiary settings, suggesting improved systematic approaches are needed.

Effectiveness of a Retrospective Drug Utilization Review on Potentially Unsafe Opioid and Central Nervous System Combination Therapy.

Drug overdose deaths are the leading cause of unintentional death in the United States, and opioid-related mortality is the primary contributor (75.2%). Among opioid-related mortalities, opioids are most commonly taken with benzodiazepines (30.1%) and antidepressants (13.4%). The utility of a retrospective drug utilization review (DUR) program initiated by a commercial health plan for members taking potentially unsafe opioid and central nervous system (CNS) combination therapy is currently unknown. To determine the effectiveness of a retrospective DUR program on potentially unsafe opioid and CNS combination therapy. This research is a pre-post study utilizing pharmacy claims data from 2.6 million commercially insured members enrolled in a health plan in the Midwest. Members were required to be at least aged 18 years as of August 30, 2013, and continuously enrolled from May 2, 2013, through February 15, 2014. Members with 1 or more paid claims for an opioid at least 200 morphine equivalent dose (MED) daily and a concur- rent supply of another opioid, benzodiazepine, or antidepressant from May 2, 2013, through August 30, 2013 (120-day preintervention period) were targeted for the retrospective DUR program. These exclusion criteria were applied: members belonging to commercial groups requiring permission on claims data analyses, missing or invalid prescriber information, or presence of pharmacy claims indicating human immunodeficiency virus or acquired immunodeficiency syndrome during the 2 years prior to the pre-intervention period. Prescribers of high-dose opioids received a mailing (intervention) containing a member-specific letter, medication profile, and satisfaction survey to determine the prescriber-perceived clinical value of the program. To assess the effectiveness of the retrospective DUR program, criteria was reapplied to identify members still meeting criteria 120 days postintervention (February 15, 2014). Paired samples t-test was used to compare pre-post results. Of 2,236,243 eligible members aged 18 years and older, 980 met DUR criteria. Prescribers for these members subsequently received a mailing regarding potentially unsafe opioid and CNS combination therapy. A total of 671 prescribers were sent a mailing regarding these 980 members. Among the 980 members meeting DUR criteria, distribution of prescriber specialty was family medicine (25.9%), physical medicine and rehabilitation (14.4%), internal medicine (13.0%), pain (9.2%), anesthesiology (7.0%), other (8.8%), and unknown (21.7%). High-dose opioids most commonly identified by the DUR were oxycodone extended release (27.6%), morphine sulfate extended release (17.7%), and fentanyl patch (13.1%). After reapplying DUR criteria to identify members still meeting criteria 120 days after the DUR, 528 members remained, representing a 28.1% reduction in high-risk opioid use. Survey response rate was 23.6% (231 of 980 surveys returned). The majority (62.3%) of respondents reported that this retrospective DUR program was useful in their daily practice. A 28.1% reduction in potentially unsafe opioid and CNS combination therapy was observed after implementing a retrospective DUR program targeting high-risk opioid use. Among members remaining high risk after the DUR, the change in total unique opioids and total daily MED was nonsignificant. Members remaining at high risk after the DUR can be targeted for further interventions such as care management and member education regarding fraud, waste, and abuse. A majority of prescribers (90.5%) self-report using their states' prescription monitoring programs when prescribing controlled substances.

Evaluation of a Retrospective Drug Utilization Review Program for the Treatment of Plaque Psoriasis: A Pilot Study

Background: Because of their increasing use and high unit costs, biologics pose challenges to payer costcontainment efforts. Creative approaches are needed to assure clinical appropriateness and eliminate unnecessary costs related to biological medications. The biologic etanercept has been approved for treatment of chronic moderate to severe plaque psoriasis in certain adults; however the costs can be over $2,000 per month. Objective: The objective of this study was to evaluate the outcomes of a specialty pharmacy’s retrospective drug utilization review (rDUR) pilot program designed to identify patients with plaque psoriasis who were prescribed a dose of etanercept inconsistent with the manufacturer recommended dosing for plaque psoriasis. Methods: This descriptive analysis evaluated a pharmacist-initiated, provider-oriented rDUR pilot program for plaque psoriasis patients using etanercept. We assessed the rDUR program’s impact on annual cost. A retrospective descriptive analysis was undertaken to assess the rDUR program’s impact on annual cost associated with changes in dosage in prescribed amounts of etanercept for patients with plaque psoriasis. We examined prescription “fills” and cost per patient pre- and post-program implementation using wholesale acquisition costs (WAC). Retrospective DUR review criteria were based on dosing information contained in the prescribing label. Results: The rDUR targeted 388 providers with 444 plaque psoriasis patients; prescriber response rate to faxed reminder letters was 65.5%. Annual costs for etanercept patients had an upper range of $37,638, and annual payer savings associated with reduced dosing regimens were projected to be an average of $22,062 per patient per year. Conclusion: Proactive therapy management approaches are necessary for specialty medications to help eliminate unnecessary health-care expenses related to unintended prescribing in excess of the manufacturer’s recommended dosing. Pharmacist-led programs to provide information regarding manufacturer dosing recommendations can effectively be incorporated into specialty pharmacy, and can significantly and positively influence prescribing and control costs.

Review of the Drug Utilization Review Program of United States 47 States and Suggestion of Policy

Review of the Drug Utilization Review Program of United States 47 States and Suggestion of Policy

Social Burden of Drug Allergy and its Prevention

Drug allergy exhibits a wide range of clinical features that partly reflect the diversity of the underlying responsible mechanisms. These range from non-immunologic idiosyncratic reactions to Gell and Coombs type 1, 2, 3, and 4 reactions. Consequently, a drug allergy may be difficult to differentiate from an adverse drug reaction. The prevalence of drug allergy varies but is assumed to account for 30% of all adverse drug reactions. In the U.S., 3.1-6.2% of all ward patients are admitted because of adverse drug reactions, and 5-10% of all out-patients or ward patients have suffered an adverse drug reaction. Nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, and radiocontrast media are the most common causes of drug allergy, but with the recent introduction of molecular anti-cancer agents, the number of drug allergy cases by these agents is soaring. Drug allergy is an important cause of mortality in admitted patients, and 1 out of every 10,000 admitted patients will die because of a drug allergy. Approximately 30% of adverse drug reactions can be prevented if previous reactions have been monitored and managed adequately. In 2006, a regional pharmacovigilance program was launched in Korea. In addition, the Korean Institute of Drug Safety and Risk Management plans to develop a nationwide drug utilization review program to monitor adverse drug reactions and to provide relevant information from the program to health professionals working in hospitals and clinics, with the aim of preventing drug allergies. Recent studies have shown a strong association between human leukocyte antigen genotypes and the severe cutaneous adverse reactions (SCARs) induced by certain drugs. Genotype prescreening may contribute to the prevention of SCARs induced by culprit drugs such as carbamazepine, allopurinol, and abacavir. (Korean J Med 2014,87:647-651)

Evaluation of the pilot program on the real-time drug utilization review system in South Korea

PurposeA pilot drug utilization review (DUR) program was initiated by the Korean government, which provided safety information in real-time at the stage of prescribing and dispensing. This study aimed to compare the “physician/pharmacist Co-DUR” system and the traditional “pharmacist-only DUR” system. MethodsData collected during a DUR pilot program from July 1 to October 31 of 2009 were obtained from the Health Insurance Review & Assessment Service. Descriptive analyses were conducted to investigate DUR-pop up alert rates, categories of alerts, the reasons for dispensing without prescription change after an alert, and changes in drug expenditures associated with the DUR. ResultsDUR pop-up alert rates were 8.55% at clinics and 1.90% at pharmacies in the physician/pharmacist Co-DUR, whereas the rate was 2.22% in the pharmacist-only DUR. Rates of pop-up alerts were high for between-prescription ingredient duplication at pharmacies, whereas for clinics, the rate for drug-pregnancy contraindications was high. A greater reduction in drug expenditure was estimated in the physician/pharmacist Co-DUR compared to the pharmacist-only DUR. ConclusionsThe physician/pharmacist Co-DUR has better sensitivity at detecting potential adverse drug events than the pharmacist-only DUR. Pharmacists also have opportunities to double-check prescribed drugs when doctors do not voluntarily modify pop-up alerts. Further comprehensive study will be needed to confirm the results of pilot program that favored the physician/pharmacist Co-DUR.

Impact of a drug utilization review program on high‐risk use of prescription controlled substances

Prescription drug abuse has prompted considerable concern. We evaluated a retrospective drug utilization review program to reduce controlled substance use among individuals with high-risk utilization. We analyzed pharmacy claims from a large pharmaceutical benefits manager. For each eligible member, we calculated a controlled substance score based on the number and type of claims, prescribers and pharmacies, and utilization patterns over three months. Two state health plans sent controlled substance letters to prescribers of members meeting or exceeding a plan- and pre-specified controlled substance score. Two different state health plans did not send such letters. We used a difference-in-difference design and generalized estimating equations to quantify the impact of the program on the mean difference in reduction of the controlled substance score over six months. Eligible members in the intervention and comparison states had similar baseline mean controlled substance scores (19.0 vs. 18.6, p = 0.36). Adjusting for individuals' age, sex and pharmacy risk group score, reductions in the mean controlled substance score were greater in the intervention than comparison cohort (5.67 vs. 4.31, p = 0.01), corresponding with a 34.0% reduction in the intervention cohort compared to a 25.5% reduction in the comparison cohort. Changes were driven primarily by reductions in the number of controlled substance claims filled (30.5% vs. 23.1%, p = 0.01), as well as by a non-statistically significant trend towards reductions in the number of prescribers and pharmacies used (26.9% vs. 20.1%, p = 0.07). Retrospective drug utilization review programs may reduce controlled substance scores and claims among individuals with patterns suggesting high-risk utilization.

Psychotropic medication use in foster children: An opportunity for psychiatric pharmacists

The use of psychotropic medications in United States foster care children is an issue of growing concern among clinicians, child serving agencies, and legislators. Although pharmacologic interventions are accepted as part of multi-modal treatment strategies for many symptoms of mental illness, the relatively high use of psychotropic agents in this population, as well as the limited data on efficacy and both short and long-term adverse effect risks, have led to increased scrutiny. In addition to safety, issues of concern include indications for use, overdiagnosis, appropriate consent for treatment, oversight/monitoring of psychotropic prescribing and psychiatric consultation, and the availability of medication information for clinicians, foster parents, and care givers.

Prescribing of potentially inappropriate medications among the elderly population in an ambulatory care setting in a Saudi military hospital: Trend and cost

To explore the prevalence of potentially inappropriate medication (PIM) use in the elderly, to identify the trends and the patterns of prescribing such medication, and to calculate the associated direct medication cost of such practice in a Saudi hospital. This was a retrospective cross-sectional study of patients who were aged 65 years or older on at least one PIM. The source of our data was outpatient pharmacy prescription records at Riyadh Military Hospital (RMH) for 2002, 2003 and 2004. Beers' explicit criteria for PIM was used to identify these medications. A total of 20521 PIM were identified. The prevalence of PIM for 2002, 2003 and 2004 was 2.5%, 2.3% and 2.1%, respectively. A total of 43.6% of the patients had filled a prescription of one PIM, 18% filled two PIM and 38.4% filled three or more PIM. Digoxin accounted for 23.7% of these PIM. The most commonly prescribed medications were cardiovascular medications at 26.7%. The total direct cost that was associated with inappropriate prescribing was 518314 Saudi Riyals (US$138217) during the study period. PIM prescribing in RMH was less compared with what was published in the literature in other countries. It was unclear whether these results reflect the level of elderly healthcare services provided to RMH patients or because of underreporting. Drug utilization review programs, medical education, recruiting physicians and clinical pharmacists who are specialized in geriatrics, finding safer medications or integration of computer software to detect such medications during prescriptions entry can improve the medical services provided to the elderly.

Changes in the Effectiveness of State Medicaid Drug Program Cost‐Containment Policies Following OBRA 1990

Abstract. Containment of Medicaid pharmaceutical drug program costs continues to be an important policy problem. Perhaps the most important policy of the past two decades with significant implications for Medicaid pharmaceutical drug programs was the Omnibus Budget Reconciliation Act (OBRA) of 1990. This study analyzes Medicaid drug spending data from 1985 to 1997 to determine how OBRA 1990 influenced the effectiveness of existing drug cost‐containment policies and if the Act produced its anticipated cost savings. The descriptive evidence indicates that reductions in drug expenditure growth rates, following the passage of OBRA 1990, resulted from factors that are independent from that Act. Furthermore, the analytical evidence shows that changes in the effectiveness of major cost‐containment policies (drug formularies, drug utilization review programs, and reimbursement rates) offset, at least in part, savings from the drug rebate program included in OBRA 1990.

Prevalence of drug-related problems and cost-savings opportunities in medicaid high utilizers identified by a pharmacist-run drug regimen review center.

Despite numerous reports of state Medicaid drug utilization review (DUR) programs, little data are available about the prevalence of drugrelated problems (DRPs) in Medicaid patients. A university-based, pharmacist-run DUR program for high utilizers was created as an alternative to imposition of a statutory limit of 7 medications per month in the Utah Medicaid program in 2002. The DUR program was designed to suggest ways that high-utilizing patients could decrease their total number of medications to 7 or fewer prior to imposition of the 7-medication limit at some time in the future. To describe the experience in 1 Medicaid DUR program and to report the prevalence of DRPs and cost-saving opportunities (CSOs) among a population of Medicaid recipients who were high utilizers of prescription drugs. DRPs were identified by 5 clinical pharmacists employed by the Drug Regimen Review Center (DRRC) in Salt Lake City. The purpose of the center was to provide drug therapy review services for a select number of Utah Medicaid recipients (200-300 per month) who exceeded a 7-medication limit during the calendar years 2003 and 2004. Out of 391,890 eligible Medicaid recipients, 242,411 (62%) received at least 1 medication, and 16,958 (4.3%) exceeded the 7-medication limit during the review period. Of those exceeding the limit, the DRRC reviewed a total of 3,706 (21.9%) patients, representing the highest utilizers by volume of medication. The prevalence of DRPs considered clinically important in the review cohort was 79.7% of patients, including therapeutic duplications in 54.6% of patients, dose form optimization in 29.7%, and inappropriate uncoordinated care in 25.3%. The average pharmacy cost per month for patients with at least 1 DRP was 1,081 dollars; by contrast, the average pharmacy cost per month for all other patients receiving at least 1 prescription was 91 dollars. Approximately 4% of Medicaid recipients exceeded the 7-medication monthly limit. Among the 22% highest utilizers in this group, 48% of nursing home residents and 87% of ambulatory recipients had at least 1 DRP, or an overall rate of 80% of high-use Medicaid recipients or as much as 3.2% of the Medicaid population.

Evaluation of Drug Utilization Review Programs—Reply

Evaluation of Drug Utilization Review Programs—Reply