By: Dr. Aqeel Nasim (M.Phil Pharmacy Practice) INTRODUCTION OF DRUG UTILISATION REVIEW (DUR) Drug utilization review (DUR) is defined...
By: Dr. Aqeel Nasim (M.Phil Pharmacy Practice)
INTRODUCTION OF DRUG UTILISATION REVIEW (DUR)
Drug utilization review (DUR) is
defined as “an authorized, structured, ongoing review of prescribing,
dispensing, and use of medication” and is the professional responsibility of
the pharmacist entrusted to provide safe and effective care (Gupta, 2021).
Prescription medications are an
essential part of health-care provision. Drugs, on the other hand, can only
assist patients if they are administered correctly, which means that physicians
must prescribe them based on evidence. Medication utilisation review (DUR)
programmes are a popular technique of reviewing and addressing the
appropriateness of drug prescriptions (Pharmacists,
1988). A DUR programme is a continuous technique
of ensuring the quality of drug use by employing criteria and attempting to
rectify drug usage that does not meet these standards; the efficacy of remedial
measures is monitored (Stolar, 1978).
DUR gives health plans internal
controls to guarantee that medication therapy is safe, medically required, and
cost-effective. It also implements and supports DUR programmes for Medicaid
managed care organisations and state Medicaid plans (Altman &
Lewin, 2000).
Key Functions of DUR
|
Avoid
negative drug responses. |
|
Duplicate
therapies should be avoided. |
|
Check
to see if there is a more cost-effective option. Make sure the medicine is
effective and suitable. |
|
If
clinical recommendations have changed, make modifications to prescriptions. |
|
Determine
whether or if there is a problem with fraud or abuse. |
|
Support
the DUR and Pharmacy & Therapeutics (P&T) boards. |
|
Management
of the formulary |
|
Use of
generic drugs |
|
Decisions
on prior authorisation |
|
Analyses
of prescribing patterns and consequences |
|
Statistics
from clinical call centres |
|
Results
of prescriber education |
Classifications of DUR
DUR is divided into three
groups:
|
Prospective |
Prior
to dispensing medicine, a patient's pharmacological treatment is evaluated
prospectively. |
|
Concurrent |
Continuous
monitoring of medication therapy throughout the duration of treatment is
known as concurrent monitoring. |
|
Retrospective |
After the
patient has received the medicine, the pharmacological therapy is reviewed. |
PROSPECTIVE
DUR
Medicine orders are compared
against criteria before the patient receives the drug in prospective DUR. This
form of examination is beneficial for its prevention potential as well as the
specific patient-centered therapy it provides.
The evaluation of
pharmacotherapy before the patient takes the first dose of medicine is known as
prospective DUR. During the prescription screening procedure, pharmacists may
do a prospective assessment of the patient's drug regimen. Before the patient
receives the medicine, the pharmacist is able to identify and fix issues. In
their everyday practise, pharmacists conduct prospective evaluations by
evaluating a prescription medication's dose and recommendations while checking
patient information for potential drug interactions or duplication therapy (Schafermeyer,
2008). Although participation in prospective DUR
has always been voluntary for pharmacists, when OBRA '90 went into force in
January 1993, prospective DUR became a compulsory role (Chui, 2000).
Elements of Prospective DUR
1. a
correct and thorough prescription/medical order
2. Allergies
and unfavourable outcomes
3. Choose
the right medicine
4. Recommended
medication regimen - suitable dose, frequency, duration/length of therapy,
formulation, and administration route
5. Interactions
between drugs
6. Duplication
of therapeutics
7. Appropriate
use and therapeutic results - new/refill prescriptions/med orders
8. Misuse
and Abuse
Example of Prospective DUR
A typical result of a
prospective DUR is the discovery of drug-drug interactions. For example, a
patient using warfarin to avoid blood clots may be recommended a new medicine
to treat arthritis by a different doctor. If all of these factors are present,
the patient may undergo internal bleeding. The pharmacist would note the
probable medication interaction while checking the patient's prescriptions and
call the physician to inform him or her of the concern (Peng et al.,
2003).
CONCURRENT
DUR
Concurrent DUR entails reviewing
medication orders while on treatment. This form of assessment is helpful when
medication therapy has to be adjusted based on continuing diagnostic and
laboratory testing (Wertheimer,
1986).
Elements of Concurrent DUR
A concurrent DUR seeks to
improve current prescription behaviours while also avoiding future incorrect
prescribing (Lipton &
Bird, 1993). Concurrent DUR
monitoring compares drug usage to criteria set during treatment, similar to
prospective monitoring. The fundamental distinction between the two is that
treatments with contemporaneous monitoring are corrective.
1. Interactions
between drugs and diseases
2. Interactions
between drugs
3. Modifications
to drug dose
4. Precautions
for drug users (age, gender, pregnancy, etc.)
5. Overutilization
and underutilization
6. Interchange
of Therapeutics
Example of Concurrent DUR
In a hospital, for example, a rule
may be set that gentamicin dosage should be determined using optimum body
weight and modified depending on renal and hearing tests. The clinical
pharmacologist or pharmacist would monitor these parameters on a daily basis,
informing the prescribing physician if the dosage was calculated erroneously or
if dosage modifications were not done (Peng et al.,
2003).
RETROSPECTIVE DUR
Retrospective DUR entails
looking back on medication prescriptions and usage after they've happened.
Although it is the simplest and least expensive method, retrospective DUR does
not allow for the modification of therapy for the patients whose data was
obtained (Fulda, Lyles,
Pugh, & Christensen, 2004).
Retrospective DUR Monitoring is
going over prescription medications with the patient after they've been given
to them. Its main flaw is that it does not allow for measures to improve drug
usage for the patients whose records were examined. It may be used to track the
same features of drug usage as prospective DUR, as well as: determining the
frequency with which a specific drug or class of pharmaceuticals is prescribed (Moore, Bykov,
Savelli, & Zagorski, 1997).
1. comparing
how doctors prescribe drugs
2. prescription
in comparison to established treatment recommendations
3. Keeping
track of the therapeutic usage of high-priced medications
Elements of Retrospective DUR
1. Use of a
generic term that is appropriate
2. Abuse/misuse
in the clinic
3. Contraindications
to drugs and diseases
4. Interactions
between drugs
5. Inadequate
treatment duration Inadequate medication dose
6. When
possible, use drugs on the formulary.
7. Overutilization
and underutilization
8. Duplication
and/or therapeutic appropriateness
Example of Prospective DUR
The discovery of a group of
patients whose therapy does not match authorised criteria is an example of a
retrospective DUR. A pharmacist, for example, may identify a group of asthmatic
patients who, based on their medical and pharmaceutical histories, should be on
orally inhaled steroids. The pharmacist can then use this information to
persuade prescribers to use the medications that have been recommended ("Drug
Utilization Review," 2019).
STEP-BY-STEP GUIDE TO CREATING A BASIC HOSPITAL DRUG UTILISATION REVIEW (DUR) PROGRAM
PHASE 1: PLANNING
1. Create a
DUR Committee.
2. Procedures
and policies should be written.
3. Define
all hospital locations or departments where medications are used (e.g.,
emergency room, intensive care unit, radiology, surgical department, medical
department).
4. Determine
which medications should be considered for inclusion in the programme.
5. Assess
the resources available for developing criteria, collecting data, and
evaluating the programme, as well as the pharmaceuticals to be included.
6. Select
features of medication usage to monitor and analyse for each medicine
(indications, dose, dosage form selected, etc.).
7. Make a
list of criteria and set performance goals.
8. Create a
timetable and a process for data gathering and assessment.
9. Educate
hospital personnel on the DUR programme and current eligibility requirements.
PHASE 2: Data Collection
10. Gather
information.
11. Analyse
the data to see if there are any drug-related issues.
PHASE 3: Intervention
12. Inform
the hospital personnel of the findings.
13. Create
and conduct interventions if a drug use issue is discovered.
14. Collect
new data on the problematic substance to see if usage has improved since the
intervention.
15. Re-evaluation
results should be disseminated.
PHASE 4: Program evaluation
16. At the
end of the evaluation year, evaluate all DUR programme activities and plan
programme activities for the next year (Moore et al.,
1997).
References
Altman,
S., & Lewin, M. E. (2000). America's health care safety net: intact but
endangered.
Drug Utilization Review. (2019). Concepts
in Managed Care Pharmacy. 2021, from https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/drug-utilization-review
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