Retrospective Drug Utilization Review Research Articles

RX4 A DYNAMIC MODEL OF BUDGET IMPACT ANALYSES

intervention letters on the recurrence of exceptions, multiple regression models were developed using prescriber-level mean time (in days) between exceptions. In addition, the effect on medical costs and utilization was measured for a subset of data using a pre-post design with a control group. Pre-post periods were defined as 120 days before and after the date of intervention letters dated between May 1 and August 31, 2003. Controls were selected by matching to intervention cases using the propensity score methods. Sensitivity analysis was performed using varying time windows and bootstrap samples. Outcomes related to PMPM inpatient admissions, emergency room visits, and physician office visits were analyzed. RESULTS: Of 51,214 prescribers who had two or more exceptions during the 23-month time period, 6233 (12%) were randomly selected to receive intervention letters (ranging from one to 19). Model coefficients indicated that the time to exception was longer by 6.5 days (p < 0.001) as prescribers received additional intervention letters, after adjusting for the number of exceptions, severity level, and average patient age. There were no significant differences in medication costs from pre to post time periods, or between groups (study vs. control). However, the study group had fewer PMPM inpatient admissions and emergency room visits. CONCLUSIONS: Retrospective drug utilization review processes can have a positive effect in delaying next exceptions for prescribers and reducing utilization of health care services.

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

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

Retrospective drug utilization review, prescribing errors, and clinical outcomes.

Retrospective drug utilization review is required of all state Medicaid programs and is performed by most private-sector prescription programs. However, it has not been shown to improve clinical outcomes or reduce the rate of potential prescribing errors, known as "exceptions." To look for an effect of retrospective drug utilization review on the rate of exceptions and of clinical outcomes in patients with an exception. Longitudinal ecologic study of the rate of exceptions, controlling for preintervention trends and calendar time; and a cohort study of all-cause and cause-specific hospitalizations in patients with an exception, controlling for potential individual-level confounders in 6 Medicaid programs using the same software in the mid-1990s. The rate of exceptions was examined as a function of retrospective drug utilization review implementation. In addition, before-after comparisons were made of the incidence of all-cause and cause-specific hospitalization in patients with exceptions. We found no reduction in the rate of exceptions coincident with retrospective drug utilization review implementation (rate increase, 0.064 exceptions per 1000 prescriptions per month; 95% confidence interval [CI], -0.006 to 0.133). We also found no effect of retrospective drug utilization review on the incidence of all-cause hospitalization (odds ratio, 0.99; 95% CI, 0.98-1.00) or cause-specific hospitalization. These results persisted in multiple subgroup analyses. Study states intervened using physician alerts in between 1% and 25% of exceptions. We were unable to identify an effect of retrospective drug utilization review on the rate of exceptions or on clinical outcomes. Given the lack of evidence for effectiveness, and suggestions from previous research of possible harm, policymakers should consider withdrawing the legislative mandate for retrospective drug utilization review.

Effect of Practitioner Education on Adherence to Asthma Treatment Guidelines

To determine whether a letter-based intervention program submitted to prescribers and pharmacists would improve drug therapy in users of high-dose beta(2)-agonists (HDBs). Retrospective drug utilization review. The intervention group consisted of 135 asthmatic patients (identified through ICD-9-CM codes) in the Connecticut Medicaid Program who submitted >1 claim per month for short-acting beta(2)-agonists (over a 6-mo period). Patient-specific intervention packets were mailed to the patients' prescribers and pharmacists, and their use of long-term control agents and healthcare utilization was evaluated over 6 months. These variables were compared with a comparison group (n = 510) of asthmatics drawn from the same Medicaid program who were not considered to be high-dose users of short-acting beta(2)-agonists at baseline. Prior to the intervention, the intervention group used fewer long-term asthma control agents as compared with the comparison group (58% vs. 96%; p < 0.001); there was no significant difference after the intervention program (65% vs. 71%; p = 0.169). The acquisition of spacers was greater in the intervention group than in the control group after the intervention (7% vs. 2%; p = 0.007). At the end of the 6-month intervention period, 46% of patients in the intervention group were no longer HDB users (p < 0.001). The higher frequency of prescriber office visits in the intervention group than the comparison group before the intervention (0.46 +/- 0.82 vs. 0.25 +/- 0.66; p < 0.001) was not evident after the intervention program (0.24 +/- 0.63 vs. 0.18 +/- 0.60; p = 0.283). This intervention program had modest impact on improving the use of long-term control agents and reducing prescriber office visits.

Effect of Age on the Conformity Rate to Short-Acting Beta-Agonist Use Criteria in Asthma

Study Objectives. Assess compliance to asthma guidelines and influence of age concerning inhaled short-acting β2-agonist (SABA) utilization in 5 to 45-year-old asthmatic subjects in the province of Quebec. Design. Population-based retrospective drug utilization review using a computerized database of claims submitted to a private prescription drug insurance plan. Patients. Subjects who received at least one outpatient prescription of SABA (age range, 5 to 45 years) for the treatment of asthma between 01 1996 and 12 1997. Measurements. Percentages of patients whose use was appropriate according to the criteria regarding the average daily dose of SABA. Use was considered appropriate if the consumption rate corresponded to a maximum of two puffs per day (Salbutamol equivalent) in subjects who did or did not use inhaled corticosteroids (ICS) at an estimated maximum dose of 800 mcg/day of Beclomethasone (BDP) equivalent for the 5 to 11-year-olds and 1000 mcg/day for the 12 to 45-year-olds. Results. In 1996, use was found to be appropriate for 74.4% of the 394 patients who received an SABA without ICS as compared with 70.7% for 593 patients in 1997. If we consider those who received an ICS at low to moderate doses, appropriate use was found for 51% of the 375 patients in 1996 and 57.6% for 254 patients in 1997. If we exclude patients who did not renew their SABA, appropriate use drops to 46.3% for 1996 and 34.3% for 1997 for the group who receive SABA without ICS (29.4% and 37.6%, respectively, for those with ICS). There is a relationship between age and appropriateness; the percentage of appropriateness was higher for the younger ones (5 to 14-year-old group; 83% in 1996 and 86% in 1997 for the patients who received a SABA without IS and 58.5% in 1996 and 73% in 1997 for the patients who received a SABA using ICS (p < 0.05). Conclusion. Our results indicate that adherence to asthma guidelines concerning SABA is poor. SABA are still overused, particularly among ICS users, which might be explained by undertreatment or poor compliance. Appropriate SABA use was significantly more common among younger groups (p < 0.05). This can be explained by better treatment in that age group, better compliance or less severe asthma.

Ambulatory Use of Inhaled β2-Agonists for the Treatment of Asthma in Quebec: A Population-Based Utilization Review

To assess whether the utilization of inhaled short-acting beta(2)-agonists (ISAB) and inhaled long-acting beta(2)-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations. Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma. Province of Quebec, Canada. Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998. Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3). Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists. Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Evaluation of vancomycin use in a large university-affiliated hospital in eastern France in 1999.

In 1999, we conducted a retrospective drug utilization review to determine the volume and pattern of vancomycin use in a university-affiliated hospital in eastern France. Total vancomycin use was determined and expressed as vancomycin courses per 100 admitted patients and defined daily doses (DDD) of vancomycin per 100 patient-days. The indication for vancomycin use was classified as appropriate or inappropriate according to the guidelines issues by the HICPAC. A total of 311 vancomycin courses were given, as 2098 DDD, giving crude incidences of 1.17 courses per 100 admitted patients and of 1.19 defined daily doses per 100 patient-days. The frequency of appropriate courses was 66.7%. Of the 63 inappropriate courses of vancomycin, 39.7% and 28.6% were empiric therapy for nosocomial and community-acquired infections, respectively, 20.6% and 6.3% were specific therapy for nosocomial and community-acquired infections, respectively, and 4.7% were prophylactic. This study shows that vancomycin use in our hospital resulted in a lower selection pressure than has been reported for US university-affiliated hospitals and that comprehensive programs to improve use of vancomycin are needed in our institution.

Drug Utilization Review: Mechanisms to Improve Its Effectiveness and Broaden Its Scope: The U.S. Pharmacopeia Drug Utilization Review Advisory Panel

Objective:To address important problems and needed changes in online and retrospective drug utilization review (OUR) programs. Emphasis is placed on reliability of OUR criteria and the shift of traditional retrospective OUR programs toward disease management and health care outcomes.Data Sources:Published literature evaluating the role of online and retrospective DUR programs.Study I Selection:Particular attention was given to studies assessing OUR criteria reliability and new interventions with retrospective DUR programs.Data Synthesis:A literature review was conducted along with an expert summary from the U.S. Pharmacopeia Drug Utilization Review Advisory Panel. Studies have revealed variations in DUR criteria that could be affecting clinical practice and patient care. Appropriate formal methodologies and use of consistent procedures in developing online prospective DUR programs and systems could help resolve these problems. Traditional retrospective DUR is also shifting to incorporate disease management and methodologies from health outcomes and pharmacoeconomics studies.Conclusion:Refinements are needed to improve the reliability and validity of online OUR criteria and to minimize false positive messages. Databases created as a result of DUR efforts have been used in new and innovative ways to incorporate health outcomes data and disease management interventions. Additional outcomes data, combined with quality assurance efforts, should increase the utility of DUR/disease management efforts in evaluating health systems while improving the effectiveness and efficiency of pharmacists’ health care interventions.

Drug Utilization Review of Sedative/Hypnotic Agents in Texas Medicaid Patients

To assess use of sedative/hypnotic agents in Texas Medicaid patients and evaluate practitioner receptiveness to intervention letters concerning sedative/hypnotic prescribing generated by the Texas Medicaid Drug Utilization Review (DUR) Board.Retrospective DUR.Texas Medicaid retrospective DUR program.244 Texas Medicaid patients and 291 Texas physicians.Patient profiles for Texas Medicaid patients were reviewed retrospectively to quantify sedative/hypnotic prescribing practices. Intervention letters were prepared and sent to physicians directly involved in the care of patients receiving excessive sedative/hypnotic therapy. Physician responses were categorized based on information presented in the intervention letter and circumstances surrounding the identified patient. Prescribing practices were assessed approximately 1 year after the intervention to determine the impact of intervention letters on prescribing.Physician response to intervention letter.Responses were received from 208 of 291 physicians (71.5%). Approximately 40% of physicians agreed in principle with the suggestions offered by the Texas Medicaid DUR Board to minimize chronic sedative/hypnotic use. Almost one-half of these physicians had discontinued sedative/hypnotic therapy for the identified patients 1 year after the intervention. Approximately 9% justified continued sedative/hypnotic use based on patient diagnosis or refractory response to treatment, and 55 physicians (26.4%) were unwilling to alter therapy because of patient-specific factors.Through the use of retrospective DUR, Texas Medicaid patients receiving excessive amounts of sedative/hypnotic agents were identified and improvements in sedative/hypnotic therapy were initiated. DUR can be useful not only in identifying problem areas, but also in encouraging physicians to modify prescribing practices through educational means.

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...

Positive impact of a follow-up phone call to community pharmacies in a medicaid drug utilization program.

To evaluate the impact of including community pharmacists in strategies to alter excessive prescribing of antiulcer medications (AUMs) in a statewide drug utilization review (DUR) program. Mailing educational materials to physicians is a common intervention strategy of retrospective DUR programs. However, pharmacists are typically left out of this process, ignoring a possibly influential healthcare provider. Patients without gastroesophageal reflux disease who received > or = 1.0 normalized therapeutic equivalents (e.g., 1.0 NTE = ranitidine 300 mg/d or omeprazole 20 mg/d) for five of six prior months were included. The pharmacists and physicians of these patients were divided into one of three geographically distinct groups: group 1 physicians received mailed materials only (pharmacists were not contacted); group 2 physicians and pharmacists received mailed materials only; and group 3 physicians and pharmacists received mailed materials, and the pharmacists were contacted by phone. Mean NTE and AUM costs were analyzed six months before and six months following the intervention. One hundred thirty-eight, 329, and 248 patients were included in G1, G2, and G3, respectively. There was a 12.4%, 8.0%, and 14.0% reduction in NTE for G1, G2, and G3, respectively. G1 AUM cost decreased 7.7% ($7710); G2 decreased 6.8% ($14 037); G3 decreased 20.5% ($26722). The total decrease in AUM cost for the entire cohort from before to after the intervention was $48469 (p < 0.05) in the six months following the intervention. A follow-up phone call to pharmacists in a statewide DUR intervention enhances the effectiveness of DUR interventions under the conditions studied. Enlisting the support of community pharmacists may improve the cost savings of these interventions.

Inter- and intrarater reliability of retrospective drug utilization reviewers.

To assess inter- and intrarater reliability among 23 pharmacist and physician retrospective drug utilization reviewers and to assess interrater reliability after a reviewer training session. Exploratory study. Maryland Medicaid's retrospective drug utilization review (DUR) program. 23 physician and pharmacist retrospective drug utilization reviewers. None. Profiles rated as "intervention indicated" or "intervention not indicated." Cochran's Q test, overall percent agreement, and the unweighted kappa statistic were used in the analysis of review consistency. Intrarater reliability showed substantial consistency among the 23 reviewers; the percent agreement was 82.9% with kappa = 0.66. Interrater reliability, however, was poor, with an overall agreement of 69.6% and kappa = 0.16. Interrater reliability was also poor after a one-hour reviewer training session (agreement 81.8%, kappa = -0.19). The implicit review process used in the retrospective DUR program that we evaluated was unreliable. Since reliability is a necessary but not sufficient condition for validity of an indicator of inappropriate drug use, the validity of the DUR implicit review process is in question.

A Comparison of Retrospective and Concurrent Drug Utilization Review of Omeprazole

Objective: To compare the appropriateness of omeprazole prescriptions in a concurrent drug utilization review (DUR) with the assessed appropriateness of a retrospective DUR. Methods: A retrospective DUR of omeprazole was conducted on prescriptions written from August 23, 1993, to October 8, 1993, in a 340-bed university hospital. This DUR served as a baseline for a concurrent DUR that began on January 27, 1995, and ended on March 16, 1995. The concurrent DUR integrated three steps aimed at improving the quality of omeprazole use: Approval of the criteria by the pharmacology and therapeutics committee of the hospital, distribution of a drug bulletin to all physicians, and a pharmacist's verbal recommendations to physicians whose prescriptions did not meet explicit criteria. Results: Twenty-nine and 64 prescriptions were reviewed in the retrospective and concurrent DURs, respectively. During the concurrent DUR, the pharmacist made 34 verbal recommendations. Of these, 25 (74%) were agreed to by the prescribers. In comparison with the retrospective DUR, the percentage of prescriptions meeting the criteria of indication, combination therapy, and dosage went from 38% to 75% (p &lt; 0.05), from 76% to 95% (p &lt; 0.05), and from 83% to 100% (p &gt; 0.05), respectively, during the concurrent DUR. Conclusions: The concurrent DUR appeared to successfully improve the quality of omeprazole utilization in the hospital.

Thrombolytics-a drug utilization review in a district general hospital

Background: Retrospective drug utilization review (DUR) can be of benefit in determining the extent to which recommendations derived from clinical trials are carried out in practice.Objective: To determine whether thrombolysis was given in accordance with hospital guidelines.Method: A retrospective DUR of the treatment of patients with a diagnosis of myocardial infarction (MI) admitted to Borders General Hospital during April–December 1993 was carried out.Results: Forty-eight per cent of these patients received thrombolysis, representing 52% of all patients with a definite diagnosis of MI. The most frequent reason for thrombolysis not being given was atypical presentation, particularly ECG changes not in accordance with those described in the hospital guidelines for diagnosis of MI. Contraindications and late presentations were very few in number. Appropriate reasons were identified for all patients who did not receive thrombolytic therapy. Mortality both at discharge and at 6 months was slightly greater in these patients than in treated patients.Conclusion: Thombolytic drugs were used in line with the hospital guidelines in most cases, although there was no identifiable reason for the use of alteplase instead of streptokinase in two cases.

Thrombolytics-a drug utilization review in a district general hospital

Retrospective drug utilization review (DUR) can be of benefit in determining the extent to which recommendations derived from clinical trials are carried out in practice. To determine whether thrombolysis was given in accordance with hospital guidelines. A retrospective DUR of the treatment of patients with a diagnosis of myocardial infarction (MI) admitted to Borders General Hospital during April-December 1993 was carried out. Forty-eight per cent of these patients received thrombolysis, representing 52% of all patients with a definite diagnosis of MI. The most frequent reason for thrombolysis not being given was atypical presentation, particularly ECG changes not in accordance with those described in the hospital guidelines for diagnosis of MI. Contraindications and late presentations were very few in number. Appropriate reasons were identified for all patients who did not receive thrombolytic therapy. Mortality both at discharge and at 6 months was slightly greater in these patients than in treated patients. Thombolytic drugs were used in line with the hospital guidelines in most cases, although there was no identifiable reason for the use of alteplase instead of streptokinase in two cases.

Extent and variation of omeprazole prescribing in an elderly population of Ontario.

To determine the extent of omeprazole prescribing in the senior population of Ontario over a 1-year period; the variation in omeprazole prescribing for this population according to age group, gender, and geographic region: and the extent of inappropriate prescribing of omeprazole for this population. Retrospective drug utilization review of prescription drug insurance claims. The Ontario Drug Benefit (ODB) program claims database. The following outcomes were measured: the proportion of seniors in Ontario who received a prescription for omeprazole from April 1, 1992 to March 31, 1993: effects of age group, gender, and geographic region of residence on omeprazole prescribing; and the extent of inappropriate omeprazole prescribing according to the ODB criteria for use. Prescribing of omeprazole was defined as inappropriate if a first-line antiulcer drug (i.e., histamine2-receptor antagonist) was not prescribed within 1-6 months of the first prescription claim for omeprazole. A total of 29,936 seniors in Ontario received omeprazole from April 1, 1992 to March 31, 1993 (2.53 recipients per 100 eligible population). The age-gender group most frequently prescribed omeprazole was women 65-74 years, followed by women and men 75 years or older, and then men 65-74 years. Omeprazole prescribing varied widely among the 48 provincial counties (range of 1.66 recipients per 100 eligible population to 4.52 recipients per 100 population, p < 0.001). There was no evidence of a clustering effect in omeprazole prescribing at the county level. Prescribing of omeprazole was considered to be inappropriate for 80.5% of recipients. This study demonstrated the ineffectiveness of the ODB limited-use program in controlling omeprazole prescribing. Further study should be done to examine determinants of variation in prescribing by geographic region.

Retrospective drug utilization review software systems: perspectives of state Medicaid DUR directors.

To determine the desirability or perceived need of retrospective drug utilization review (DUR) software system characteristics. A 32-item questionnaire. Ambulatory DUR directors covering more than 33 million patients. Medicaid DUR directors from 49 states and the District of Columbia. Five-point Likert scale measures of importance of system and vendor characteristics. A 100% response rate was achieved. Respondents rated the ability to change or modify criteria as very important and thought it was important to receive criteria sets from software vendors. Respondents believed cost-savings methodologies should be clearly defined and false positive DUR criteria should be minimized. Through the implementation of the Omnibus Budget Reconciliation Act of 1990, considerable experience in ambulatory DUR programs has been achieved. Respondents believed the ability to change DUR criteria was very important and they thought it was important to have a set of criteria supplied from software vendors. Critical issues of criteria development, cost-savings methodologies, minimizing false positive criteria, and outcomes assessment from DUR programs were important issues to DUR directors.

Retrospective drug utilization review and the behavior of medicaid prescribers: an empirical marginal analysis

The objectives of this study were to evaluate the effectiveness of drug utilization review (DUR) letter intervention on reducing the cost of medications under Medicaid. The target drugs in this study were six antiulcer agents prescribed for Alabama Medicaid recipients. The study group consisted of 100 prescribes who received DUR intervention. A total of 3776 prescribers who did not receive DUR intervention served as the comparison group. Using an interrupted time series design, these 3876 prescribers were studied before and after the implementation of the DUR program. The study found that prescribers' behavior changed after the DUP letters were sent out, resulting in a reduction in the average marginal days of drug therapy and drug reimbursement per recipient. For the target drugs, there was an average savings of $112.73 per prescriber per month and a total of $136,370.82 savings per month for the Alabama Medicaid program.

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

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

Effects of Medicaid drug utilization review intervention letters

The state of Texas Drug Utilization Review (DUR) Board, composed of six physicians and six pharmacists, meets quarterly to determine criteria for implementing retrospective DUR. The board agreed to send intervention letters to physicians concurrently prescribing: (1) two histamine 2 (H 2)-antagonists (H 2As) or (2) either any H 2A or omeprazole with sucralfate. To measure the effect of these intervention letters, approximately half of these physicians were randomly chosen to receive a letter while the others served as a control group and did not receive letters. This project focused on the H 2A or omeprazole with sucralfate intervention letters in a two-step process. Data on concurrent therapy involving two H 2As were analyzed separately and these results are not included in this report. Objective one was to examine feedback from the physicians who received the letters, and objective two was to review and compare patient profiles 6 months after the letters were sent. Analysis of Medicaid prescription claims indicated that 190 physicians had concurrently prescribed either an H 2A or omeprazole with sucralfate for 222 patients. Ninety-seven physicians (from 117 identified patient profiles) were selected to receive an intervention letter with their patient's profile or profiles, a response form, and a stamped envelope addressed to the Texas Department of Human Services. A 67.5% response rate was obtained. Of these responses, 49.4% agreed with the letter and 29.1% disagreed with the letter. The remaining indicated responses such as “not my patient,” they were no longer seeing the patient, or that they did not prescribe the medication in question. Results of objective two indicated that 57.9% of the experimental group and 75.3% of the control were still receiving H 2A or omeprazole with sucralfate concurrent therapy after the 6-month postintervention observation period. This statistically significant reduction ( P = 0.011) in the percentage of patients receiving concurrent therapy for the experimental group, when compared with the control group, along with the high physician response rate and moderately high agreement rate, indicate that intervention letters are an appropriate way to inform physicians of potentially inappropriate prescribing.