Retrospective Drug Utilization Review Research Articles

Drug utilization review in ambulatory settings: state of the science and directions for outcomes research.

There are escalating national pressures to analyze pharmaceutical outcomes and to develop drug-related clinical guidelines. These interests coincide with passage of the Medicaid Rebate Law (OBRA, 1990), which mandates the implementation of prospective and retrospective drug utilization review (DUR) programs by Medicaid in 1993. This report investigates DUR programs that target outpatient drug therapies. The authors present a conceptual framework that identifies the factors influencing drug prescribing and the range of potential patient outcomes. Current types of DUR interventions and their applications are described, in addition to problems that hinder implementation or evaluation of DUR programs. DUR evaluation studies are reviewed, and a critique identifies the limitations of available DUR research. The authors recommend an expanded DUR policy research agenda, strongly suggesting that priority be given to studies in the following areas: DUR criteria development and validation; prevalence of prescribing problems and their association with patient outcomes; efficacy, toxicity and costs of therapeutic alternatives; and DUR program evaluation. The overall conclusion is that the state of the science pertaining to DUR is not well developed. The potential of DUR may not be realized due to the lack of resources needed to design, implement, and evaluate effective programs. Instead, DUR efforts may be limited to cost-containment issues without due consideration of quality-of-care outcomes. The authors call for rigorous evaluation efforts to inform DUR design and implementation, thereby assuring more rational prescribing and enhancing patient outcomes.

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

Drug use evaluation (DUE) or drug use review (DUR) for the ambulatory care setting is creating many opportunities to improve the pharmaceutical care provided by pharmacists. This study documents one year of peer-review interventions based on a retrospective drug utilization review software system (Qualisure, Q-A, Inc.) that screens patient profiles for a high likelihood of drug therapy problems. Letters are written to physicians and pharmacists providing care to these patients. The software identifles frequent opportunities for selecting therapeutic class alternatives to prescribed agents. Antibiotics, antihistamines, nonsteroidal anti-inflammatory drugs, and antidepressants were the classes for which therapeutic class alternatives were most often recommended.

Comprehensive Drug Utilization Review: Adding Physician Outreach to Concurrent and Retrospective Drug Utilization Review

Communication about drug selection and use between physicians and pharmacists has changed in the last two decades. The enhanced clinical education offered to pharmacists and the recognition by many physicians that keeping up with advances in drug therapy is exceedingly difficult and time consuming has facilitated the change. Accordingly, hospitals and long-term care facilities have formalized the clinical role of the pharmacist in drug selection, use, and/or monitoring through the use of drug utilization review (DUR) programs, specifically called drug use evaluation (DUE) and drug regimen review (DRR), respectively, in these environments. A majority of drug therapy decisions, however, occur outside of these closed environments where the physician's drug information is often provided by representatives of the pharmaceutical manufacturers and where comprehensive DUR programs are in their infancy. As a source of information on drug products available from their company, sales representatives perform a valuable service, but their information, understandably, is focused on the advantages of their products. Making appropriate choices from alternative therapies that are more plentiful, complex and expensive than ever requires the physician to have access to current, scientifically valid, objective and unbiased information. Building on the value inherent in concurrent and retrospective DUR programs and on research conducted in the early 1980s, Medco Containment Services has developed a program that brings this type of prescribing information directly to physicians in their offices. Called the Optimal Therapeutics ProgramSM (OTPSM), Medco's program is fully operational in the Commonwealth of Massachusetts and is the vehicle for bringing clinically relevant, objective, and cost-effective prescribing information to physicians for application in the ambulatory care marketplace. This innovative program augments concurrent and retrospective DUR, delivering truly comprehensive DUR services. OTP also provides an opportunity for highly motivated and skilled pharmacists to shape their emerging role as drug information consultants.

Ciprofloxacin Drug Utilization Review and Prospective Drug use Evaluation

Ciprofloxacin is a fluoroquinolone antimicrobial with activity against both gram-negative and -positive bacteria including pseudomonal and staphylococcal species. It is the only available oral agent possessing this unique spectrum of activity that achieves serum concentrations adequate to treat a variety of systemic infections. A retrospective drug utilization review and a prospective drug use evaluation of ciprofloxacin were performed to determine if the agent was being used for appropriate indications, to ensure correct dosing and appropriate monitoring, and to determine whether its use is cost effective at the Veterans Administration Medical Center, Cleveland (VAMCC). For the retrospective review, 40 patients' charts were randomly chosen for review from computerized inpatient and outpatient prescription records. Drug use review criteria were developed by the Pharmacy Service and Infectious Disease Section. For the prospective evaluation, data were collected for all inpatient and outpatient requests for ciprofloxacin during a six-month period (May to November 1988) using the same criteria as in the retrospective study. Cost analysis was performed by identification and cost comparison of alternative therapy and by estimating the number of days saved by using appropriate oral therapy. All charts from the retrospective review were found to meet criteria for appropriate use. All patients for whom documented follow-up was performed had microbiologic or clinical cures. In the prospective evaluation, 168 patients were started on ciprofloxacin. Ninety-five percent of patients had appropriate justification for use according to criteria. Drug cost savings for the six-month period was +14,962.54 or +29,925.08/year. This covered drug and minibag acquisition costs only. An estimated 127 hospital days were saved (shortened length of +71,717.00 or +143,434.00/year.(ABSTRACT TRUNCATED AT 250 WORDS)

Internal Standards: Rationale for Use in a Drug Utilization Review Program

The comparison of drug usage data gathered from different institutions would be easier if standardized criteria were employed. There are, however, major difficulties encountered in gaining approval of such criteria from different physician groups. To facilitate the criteria approval process, "internal standards" were developed. These internal standards reflected the acceptable deviations from the standardized criteria, hence, permitting flexibility for innovation in drug therapy. A retrospective drug utilization review was conducted in two hospitals. The internal standards assigned were very similar to the 0 percent-100 percent standards recommended by InterQual except for the criteria on monitoring parameters and duration of therapy. It would appear from these preliminary results that the assignment of internal standards enhances the use of standardized criteria which, in turn, will allow comparisons of data.

Drug-Induced Illness

To the Editor.— In the prospective epidemiological study by Caranasos, Stewart, and Cluff (228:713, 1974) quantifying the problem of drug-induced illnesses, we were particularly interested in their finding that 2.9% of all admissions to their hospitals' medical service were due to drugs and that 6.2% of these patients died. This is an overall mortality for the medical services of 0.18% that can be directly attributed to adverse drug reactions (ADRs). We have been singled out as mythmakers in a speech by the Pharmaceutical Manufacturers Association Board Chairman, Richard M. Furlaud, at their last convention. In a paper 1 that we presented describing a new retrospective drug utilization review system that would lessen the hazards of drug therapy, we attempted to estimate the number of deaths in the United States due to ADRs on the basis of data available to us at the time ( Bull Johns Hopkins Hosp 119:299, 1966; Can Med