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.
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.
