DRUG UTILIZATION REVIEW

Drug utilization review (DUR) programs have 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.”

DUR programs differ from drug utilization studies, which are time-limited investigations that measure drug use, but do not necessarily assess appropriateness or attempt to change practice.

Recently, the use of clinical decision support within computerized prescriber order entry (CPOE) programs has risen dramatically. The use of such programs to improve prescribing can be considered a form of prospective DUR in which prescribers are the targets of interventions

Generally, the DUR process involves comparing actual behavior to explicit, prospectively established standards, referred to as criteria. For example, a commonly used criterion is that patients should not receive more than one non steroidal anti-inflammatory agent at any one time. Criteria have been developed to identify the following types of problems: drug–drug interactions, drug–disease interactions, drug–age interactions, drug–allergy interactions, use of too high or too low a dose, duplication of therapeutic class, excessive duration of therapy, obtaining prescription refills sooner or later than should be needed, failure to prescribe a known effective agent in patients with certain conditions, abuse of psychoactive medications, and use of a more costly agent when a less costly agent is available. After developing criteria, the next step in the DUR process is to measure adherence to explicit criteria by examining individual-level data. Instances in which medication use does not agree with criteria are called exceptions.

Next, interventions are implemented where appropriate, often following an implicit review. Although the general model for DUR does not require that practitioners be made aware of individual exceptions occurring in their patients (that is, interventions can be made based on aggregate rather than individual findings), this step usually involves alerting the physician and/or pharmacy of record as to the occurrence of the specific exception.

There are different settings in which the DUR model is applied.

Outpatient retrospective DUR programs use

computerized administrative data (i.e., pharmacy and medical claims data maintained for billing and other administrative purposes) to identify exceptions that are then reviewed by a physician or pharmacist, or by a committee of health professionals, and result in an intervention (e.g., a mailed alert letter to the physician). The alert letter typically describes the DUR program and the criterion, and provides literature references supporting the criterion and a patient profile demonstrating that the criterion was violated.