Prospective Drug Utilization Review Research Articles

Impact of an Educational Intervention on Hospital Pharmacists' Knowledge and Application of Substance Withdrawal Management.

Patients with substance use disorders are often encountered in an acute care setting and withdrawal management is important. Available literature reveals inadequate acute management of substance withdrawal due to lack of experience and knowledge of medications. A quality improvement project was implemented to improve hospital pharmacists' knowledge, application, and practice of inpatient opioid and alcohol withdrawal management through provision of didactic and case-based education and implementation of practice based prospective drug utilization review (PDUR). Pharmacists' knowledge of the management of alcohol and opioid withdrawal was assessed by a 10-item survey pre-and post-intervention. Twenty-one pharmacists completed the education and pre- and post-surveys. Scores for the 21 pharmacists improved significantly, with pre- and post-intervention scores of 7.33 ± 1.98 and 8.86 ± 0.91, respectively (P = .0035). Most pharmacists completed their required PDUR submission, and several pharmacist interventions were made and accepted post-education. Pharmacists indicated that the education increased their confidence and enabled them to learn new information that could be directly applied to their pharmacy practice. Providing education and requiring a PDUR improved pharmacists' knowledge, application, and practice of inpatient opioid and alcohol withdrawal management. Re-education or expanded education may be warranted to further increase pharmacists' competence.

Impact of an inpatient order verification simulation on student perceived preparedness and confidence

Background and purposeThe ability to effectively and efficiently navigate an electronic health record (EHR) to complete an inpatient prospective drug review is a vital skill that entry level practitioners must possess. The purpose of this study was to evaluate the impact of an EHR-based inpatient order verification simulation on students' perceived preparedness and confidence when reviewing the accuracy of an inpatient medication order and providing a verbal recommendation to a health care prescriber. This was evaluated by comparing survey scores pre- and post-simulation. Educational activity and settingAn educational series utilizing EHR technology was designed to simulate the sequence of tasks an inpatient pharmacist completes when processing an inpatient mediation order. This includes performing a prospective drug utilization review to identify medication-related problems, forming alternative recommendations, and verbalizing recommendations to prescriber. FindingsA total of 89 students across two cohorts (99%) completed the pre-survey; 31 students (34%) completed the post-survey. Comparison of pre- and post-survey scores resulted in significant findings for all categories: increased perceived preparedness, efficiency, and accuracy when processing or reviewing a medication order (P < .001); increased confidence when efficiently and effectively utilizing EHR technology (P < .001); increased confidence when efficiently (P < .001) and effectively (P < .001) providing a verbal recommendation to a health care prescriber. SummaryIncorporating a series of EHR-based activities simulating medication order verification and prescriber communication into the doctor of pharmacy curriculum positively impacts student perceived preparedness and confidence.

Indication or diagnosis should be required on prescriptions.

Although prospective drug utilization review and patient counseling have long been recognized as professional and ethical responsibilities of pharmacists, the implementation of the Omnibus Budget Reconciliation Act of 1990 made them legal responsibilities. Ensuring the safety and effectiveness of prescription pharmaceutical care requires that all members of the prescriber-patient-pharmacist triad are equally informed about the therapeutic plan for which the pharmacist is professionally, ethically, and legally responsible for properly implementing. Providing pharmacists with the clinical indication or diagnosis is an important and long overdue first step. DISCLOSURES: No funding was received for the writing of this article. Warholak has received grant funding through the University of Arizona from Sinfonia Rx, Pharmacy Quality Alliance, and the Arizona Department of Health Services, unrelated to this work. The other authors have nothing to disclose.

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.

Use of a fall risk evaluation in a community-based pharmacy

BackgroundFalls in older adults are a serious public health concern. They increase health care expenditure and account for more than $30 billion in direct medical costs. Medication-related problems can contribute to fall risk, and community-based pharmacists are well positioned to intervene, given their role in monitoring ongoing medications. ObjectivesTo evaluate the integration of a fall risk screening assessment (i.e., Stopping Elderly Accidents, Deaths, and Injuries [STEADI]) into community pharmacy practice and to report on the targeted medication management interventions that pharmacists made for patients aged 50 years or older with a fall risk potential. Practice descriptionA service-oriented independent pharmacy in the Midwest United States that uses an in-house clinical software program to perform a prospective drug utilization review and document clinical interventions. Practice innovationA 3-item STEADI fall risk screening assessment was administered from October 15, 2018, to January 31, 2019, to 311 pharmacy patrons aged 50 years or older taking high-risk medications. EvaluationFor those with a positive screen for fall risk, the 12-item STEADI fall risk assessment was administered. A pharmacist performed a comprehensive medication review (CMR) for these patients. Education and medication recommendations were provided. ResultsFifty-three patients (17%) responded “Yes” to at least 1 prescreening question. The mean total STEADI fall risk score was 5.7 out of 12. The most commonly reported STEADI item was a worry regarding falling (75.5%) and sometimes feeling unsteady when walking (67.9%). Education regarding falls was provided to all the patients who received the study CMR, but only 6 medication changes were made to the prescribers, of which 4 were accepted. ConclusionThe STEADI assessment was useful in identifying patients who were potentially at a risk of falls. More work pertaining to deprescribing high-risk medications for at-risk patients seems to be needed.

Toward safer prescribing: evaluation of a prospective drug utilization review system on inappropriate prescriptions, prescribing patterns, and adverse drug events and related health expenditure in South Korea.

This study aimed to evaluate the effect of the prospective drug utilization review (DUR) system introduced in Korea in December 2010 as a real-time method to improve patient safety, in terms of changes in prescribing practices, adverse drug events (ADEs), and ADE-related healthcare expenditure, using non-steroidal anti-inflammatory drugs (NSAIDs) and their common ADEs as a guide. We used an interrupted time-series study design using generalized estimating equations to evaluate changes in prescription rate and ADE-related healthcare expenditure. Cox regression analysis was used to evaluate the probability of NSAID-associated ADEs. A total of 154,585 outpatients with musculoskeletal or connective tissue disorders, without pre-existing gastric bleeding or ulcers were included in this study. The primary outcome was the level and trend change in prescription rate, drug-drug interactions, coprescribed gastro-protective drugs, and defined daily dose (DDD) of NSAIDs. The secondary outcome was the probability of ADEs and changes in ADE-related healthcare expenditure. There was a significant trend change after introducing the DUR system in terms of drug-drug interactions (-3.6%) and coprescribed gastro-protective drugs (+0.6%). The mean DDD of NSAIDs increased by 0.2. The probability of ADEs decreased overall (-1.7%) and in the high-risk group (age ≥65 years; -9.6%); however, only the latter was significant. There was no significant trend or level change in ADE-related health expenditure. The introduction of the DUR system was associated with more efficient prescribing, including a reduction in drug-drug interactions and an increase in the use of gastro-protective drugs. The system had a positive effect on patient outcome but was not associated with reduced ADE-related costs. Further studies are needed to evaluate the long-term effects of the DUR system in Korea.

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.

Check it out: A practical tool for improving medication safety

ObjectiveTo recommend incorporation of a prospective drug utilization review (DUR) checklist into the routine processing of prescription orders in the community practice setting to improve the quality and safety of pharmaceutical care. Practice innovationWe proposed a checklist that was designed to include all the elements of a prospective DUR required by the Omnibus Budget Reconciliation Act of 1990 (OBRA ‘90) and most pharmacy practice acts. ConclusionIf properly incorporated into workflow and supported by company policies and procedures, a simple DUR checklist like that proposed in this study could significantly improve the quality of pharmacists’ prospective DUR activities and the safety of medication therapy provided to patients. We also recommend that future quality metrics be created and implemented to ensure that pharmacists consistently perform this key professional responsibility.

의약품 처방·조제지원서비스(Drug Utilization Review)사업이 병용금기 처방률에 미치는 영향

Background: Since December 2010, online computerized prospective drug utilization review (pDUR) has been implemented in Korea. pDUR involves the review of each prescription before the medication is dispensed to the individual patient. The pDUR is performed electronically by Health Insurance Review & Assessment Service (HIRA), which is a Korean governmental agency, and then HIRA provides medical institutions and pharmacies with information that can be helpful to them in preventing potential drug problems such as drug/drug interactions or ingredient duplication. The aim of this study was to assess the impact of the Korean pDUR implementation on the proportion of drug-drug interactions (DDIs) using claims data from HIRA. Methods: A before-after comparison of the prevalence of DDIs between prescription was conducted, using HIRA administrative claims data of medical institution from January 2010 to December 2011. The analysis unit was the prescription issued and pairs before and after. The main outcome measures were the proportion of DDIs within- (control group) or between- physician encounters. To examine the difference, a paired t-test was applied. Results: We found that DDIs proportion between prescription decreased significantly (t=3.04, p=0.0026) after the implementation of pDUR, whereas there is no significant reduction within prescription (t=1.15, p=0.2518). With respect to the prevalence of DDIs between drug groups, the most dramatic reduction was occurred between 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors and anti-fungal agents. Conclusion: It seems effective that giving a direct feedback to prescribers by a prospective DUR. Further research is needed to assess the impact of DUR to final outcomes such as hospitalization.

Navy Commander helps military patients near and far

The Department of Defense (DoD) Pharmacoeconomic Center is a hive of buzzing activity and a melting pot of various health care personnel from the U.S. Army, U.S. Navy, U.S. Air Force, U.S. Public Health Service, DoD civil servants, and private contractors. Located in San Antonio and operating within the Military Health System, pharmacists at the center, affectionately dubbed the PEC, manage numerous facets of a world-class pharmacy benefit program. From helping deployed patients in remote locations, to analyzing a wealth of pharmacy and medication data, to overseeing a standardized formulary that stretches across three points of care, the PEC is a diverse environment for pharmacy practice.

Strategy for establishing an effective Korean drug utilization review system

Drug utilization review (DUR) system has been defined as “structured, ongoing initiatives that interpret patterns of drug use in relation to predetermined criteria, and attempt to prevent or minimize inappropriate prescribing.” This paper introduces the concept, purpose, and effective application of DUR in Korea. DUR can be classified as retrospective DUR, prospective DUR, and concurrent DUR based on the time direction of applying DUR. DUR can also be classified as quantitative DUR defined by retrospective DUR using databases including previously prescribed medicines, and qualitative DUR defined by DUR reflecting patients s clinical condition. We described the history of developing DUR in the United States and the Europe. Finally current status of DUR in Korea is described and the strategy of future settlement of DUR system in Korea is suggested.

Development and Construct Validation of the Pharmacists' Care of Migraineurs Scale

To develop the pharmacists' care of migraineurs scale (PCMS) and to evaluate its psychometric properties. Migraine is often managed suboptimally in primary care. Migraineurs frequently come into contact with community pharmacists, who have the opportunity to make a positive impact on migraineur treatment outcomes. A valid and reliable tool that measures and documents the care provided by pharmacists to migraineurs is critical to the development and evaluation of educational programs and interventions. Relevant domains of pharmacist care and their respective composite items (behaviors) were identified through an extensive literature search and the use of 2 pharmacist and 2 migraineur focus groups sessions. The resultant 45 PCMS items composed a survey questionnaire mailed to a nationwide random sample of 6000 pharmacists. Data were subjected to an exploratory principal axis factoring procedure to discern the factor structure, and as such describe the latent domains composing the pharmacist caring behaviors constructs. A total of 580 usable responses were returned, with an additional 60 returned as undeliverable, thus yielding a response rate of 9.7%. Exploratory factor analysis using principal axis factoring yielded 9 factors. However, upon examining the scree plot, communalities, and factor loadings, a reanalysis forcing a 7-factor solution yielded a more interpretable and plausible factor structure. The 7-factor solution included the following domains: (1) empathy; (2) prospective drug utilization review for newly diagnosed migraineurs; (3) medication counseling; (4) nonpharmacologic treatment plan; (5) headache sufferer triage; (6) dissemination of public health information; (7) maintenance of knowledge on migraine. Following the application of scale purification procedures, the final instrument is composed of 41 items and demonstrated a Cronbach's alpha reliability of 0.947. Cronbach's alpha reliabilities for the 7 domains ranged from 0.67 to 0.91, indicative of good to excellent internal consistency reliabilities for all the domains. The PCMS demonstrated very good construct validity and reliability. While additional validity testing is warranted, the PCMS should allow for benchmarking in the evaluation of interventions designed to improve pharmacists' care to migraineurs and for identifying correlates to effective community pharmacist migraineur care.

Current status of prospective drug utilization review.

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

The Role of Pharmacy Computer Systems in Preventing Medication Errors

To describe the controversies and review the evidence about computer-aided prospective drug utilization review (PDUR) systems. MEDLINE search of the literature. Published studies of the effectiveness of computer-aided prescription screening. One randomized, controlled trial and four nonrandomized studies constitute the evidence base. The five studies are inconclusive with respect to whether computer-aided prescription screening causes health care providers to take action, either because of a no difference finding or because there was no comparison group. In the one randomized, controlled trial, a substantial number of actions were taken by the control group whose members did not receive alerts. No study evaluated the total effect of screening by in-store and payer (online) systems. Specific research recommendations are made to increase the evidence base. Limited and inconclusive evidence about whether these systems are effective and what system features are optimal may explain the wide variation among systems in terms of what problems are screened and may also explain clinicians' uncertainty about their value. A comprehensive national research agenda for reducing medical errors should include research on the effectiveness of computer-aided PDUR.

Regression Analysis of Health Care Charges with Heteroscedasticity

SUMMARY We examine the effects of a prospective drug utilization review and patients’ characteristics on total in-patient and out-patient health care charges. Our analysis of charges is complicated by the fact that the total health care charges are skewed. A log-transformation of these charges can normalize their distribution but may not stabilize their variance. To handle these problems, we propose a linear regression model with a non-constant variance (heteroscedasticity). Using results from a fitted linear regression model for log-transformed charges, we also discuss interpreting the regression coefficients in the original scale and estimating the total health care charges to individual patients. Employing these methods, we analyse total health care charges for drug utilization review patients with hypertension and identify patients’ factors that are related to their total health care charges.

Effect of Patient Information on the Quality of Pharmacists’ Drug Use Review Decisions

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. Unblinded comparison of two groups. 28 community pharmacists in Indiana (group 1) and 32 Public Health Service pharmacists employed in the Indian Health Service (IHS) (group 2). 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. The quality of both community and IHS pharmacists' DUR decisions improved significantly at each incremental level of patient information. Pharmacists in this study made better decisions when they had access to more complete patient information on which to base their decisions.

Medicaid Drug Utilization Review and Managed Care: The Perspectives and Experiences of State Program Directors

OBJECTIVE: To obtain from Medicaid drug utilization review (DUR) program directors their perspectives on the current status of their retrospective and prospective DUR programs, and to ascertain their assessment of the current and future influence of managed care on the integrity of these programs. PARTICIPANTS: All directors of state Medicaid drug utilization review programs. DESIGN: Telephone contact and faxed survey. RESULTS: Eighty-two percent (n=42) of the program directors responded. The majority of states did not carve out their pharmacy benefit plans when contracting services from managed care organizations (MCOs). The DUR program directors commented that Medicaid agencies should put strict data-reporting requirements into their contracts with MCOs. Several of the program directors did not know whether MCOs reported to Medicaid certain data that could be potentially useful for DUR purposes, indicating that communication between the DUR program and other departments within Medicaid agencies should b...

Evaluation of Online Prospective DUR Programs in Community Pharmacy Practice

OBJECTIVE: To gain a better understanding of both the contribution that third-party Online Prospective Drug Utilization Review (OPDUR) programs make to prescription drug therapy, and the economic burden these programs impose on community pharmacy providers. DESIGN: On-site data collection. SETTING: 42 community pharmacies in Indiana. MAIN OUTCOME MEASURES: The cost per overridden OPDUR alert and the cost per nonoverridden OPDUR alert can improve the safety and effectiveness of prescription drug care by alerting pharmacists to significant medication-related problems. However, questions have arisen in recent years regarding the benefits of OPDUR programs versus the costs these programs impose on pharmacies. RESULTS: Across all third-party claims, 10.3% were associated with an OPDUR alert. Of alerts received at the pharmacy, 88.1 % were overridden by pharmacy personnel; the remaining 11.9% required an intervention by the pharmacist or technician. Of OPDUR alerts that were not overridden, interventions included consulting with the patient (55.4%), consulting the third-party payor (26.4%), and consulting the prescribing physician (17.6%). The typical OPDUR alert required 2.89 minutes of pharmacy personnel time, valued at $1.36. Overridden alerts were calculated to cost $1.20, while nonoverridden alerts cost $2.83. When the cost of resubmitting claims was factored in, the cost to pharmacies of not overriding an OPDUR alert was found to be $3.00. CONCLUSIONS: Several recommendations can be made for improving OPDUR programs. First, the selectivity of OPDUR criteria should be increased through the adoption of more evidence-based criteria. Second, there should be greater coordination between OPDUR programs and in-store DUR systems to reduce redundancy. Third, the incremental costs to pharmacies of prescriptions associated with OPDUR alerts suggest that differential levels of payment may be needed to allow pharmacy organizations to dedicate the personnel time required to adequately respond to them.

The Pharmacist's Assessment. of Second Generation On-line Prospective Drug Utilization Review

ABSTRACT: The objective of this study was to evaluate the overall perceptions of pharmacists toward a second generation on-line, prospective drug utilization review (OUR) system. A survey was conducted of ambulatory care pharmacists throughout the state of Iowa. The survey assessed pharmacists' perceptions of the clinical utility of messages, system operation, and comparison with in-store systems. There was general agreement that an on-line prospective drug utilization review (OPDURs) system adequately identifies significant patient problems. Pharmacists were divided on OPDUR being a better system than their in-store systems. In general, pharmacists were positive in assessing OPDUR for promptness, ease of use, and impact on patient care. A majority felt OPDUR should be part of the Medicaid system and that it is a valuable tool in practicing pharmacy. If viewed on ease of use, impact on patients, and general effect on practice, pharmacists were supportive of the system. In general, it would appear that the...

New York City Pharmacists and Prospective Drug Utilization Review under Obra '90

New York regulations to implement the Omnibus Budget Reconciliation Act of 1990 (OBRA '90) have been in effect more than one year yet little is known about pharmacists' experience with, or effectiveness of, the prospective drug utilization review (DUR) mandate. An anonymous questionnaire distributed to 287 New York City pharmacists and interns achieved a 67% (194) response rate. Time, personnel, and expense constraints were the most frequently mentioned implementation problems. A number of pharmacists and interns misinterpreted various prospective DUR requirements of the New York regulation. Some erroneously believe the requirement to review the drug therapy only applies to new prescriptions but not renewals. Others do not believe the pharmacist must ascertain a complete listing of all medications. Half of the respondents indicated their pharmacy has had to hire more personnel or purchase computer software to comply. Interns appeared more optimistic than pharmacists about the future success of OBRA '90. A...