Developed by the University of Washington and Washington State University


As you know, it has been difficult to provide a "Drug Use Evaluation" (DUE) skill-building experience during the pharmacotherapeutics weekend workshops. The faculty continues to believe it is worthy of inclusion in your program of study. Consequently, we would like to ensure the learning of this topic by requiring each applicant for graduation in the ExPharmD program will provide us with either:

  1. A real DUE done at sometime during your professional practice, or
  2. A proposal for implementing a DUE complete with criteria and a method of implementation.

Below is an article from the Academy of Managed Care Pharmacy. It is a great overview of Drug Use Evaluation.


The Academy of Managed Care Pharmacy

Concepts in Managed Care Pharmacy

DRUG USE EVALUATION

Approved by the AMCP Board of Directors, June 12, 1999

Objective: This Concept Paper describes, in plain English, the value of drug use evaluation (DUE), ways pharmacists use DUE to improve the quality of patient care, and ways it is implemented in the managed care setting.

Summary: DUE is defined as an authorized, structured, ongoing review of physician prescribing, pharmacist dispensing, and patient use of medication. It involves a comprehensive review of patients' prescription and medication data before, during, and after dispensing to ensure appropriate medication decision making and positive patient outcomes.

DUE is classified in three categories:
Prospective - evaluation of a patient's drug therapy before medication is dispensed.
Concurrent ñ ongoing monitoring of drug therapy during the course of treatment.
Retrospective ñ review of drug therapy after the patient has received the medication.

Why DUE is important: DUE programs play a key role in helping managed health care systems understand, interpret, and improve the prescribing, administration, and use of medications. Employers and health plans find DUE programs valuable because the results are used to foster more efficient use of scarce health care resources. Pharmacists play a key role in this process because of their expertise in the area of pharmaceutical care. DUE affords the managed care pharmacist the opportunity to identify trends in prescribing within groups of patients such as those with asthma, diabetes, or high blood pressure. Pharmacists can then, in collaboration with physicians and other members of the health care team, initiate action to improve drug therapy for both individual patients and covered populations.

The Academy of Managed Care Pharmacy (AMCP) recognizes the value of drug use evaluation (DUE) as a means of improving the quality of patient care, enhancing therapeutic outcomes, and reducing inappropriate pharmaceutical expenditures, thus reducing overall health care costs.

Introduction

DUE is an ongoing, systematic process designed to maintain the appropriate and effective use of drugs.1 It involves a comprehensive review of patients' prescription and medication data before, during, and after dispensing in order to assure appropriate therapeutic decision making and positive patient outcomes.2 Pharmacists participating in DUE programs can directly improve the quality of care for patients, individually and as populations, by preventing the use of unnecessary or inappropriate drug therapy and by preventing adverse drug reactions. Additionally, participation in DUE activities is one means by which pharmacists provide value to the health care system by exerting a positive influence on physician prescribing patterns.

The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) mandates that DUE be performed in inpatient settings to identify trends of overuse and inappropriate prescribing. Additionally, the Omnibus Budget Reconciliation Act of 1990 (OBRA ë90) mandates that pharmacists conduct prospective and retrospective medication reviews whenever an outpatient prescription is dispensed to a Medicaid recipient. Since the passage of OBRA ë90, many states have enacted their own laws or regulations requiring pharmacists to conduct medication reviews for all outpatients.

The process of DUE goes by many names. In certain settings, it may be referred to as drug utilization review (DUR). At one time, a distinction was drawn between DUE and DUR based on the notion that the former was prospective and the latter retrospective. However, most experts agree that there is little difference between the two and favor use of the term DUE. JCAHO currently espouses the nomenclature medication use evaluation (MUE).1 AMCP believes that DUE is the most common designation for processes of prospective, retrospective, and concurrent medication review in the health care marketplace and shall use this term throughout the Concepts in Managed Care Pharmacy series.

What is Drug Use Evaluation?

DUE is defined as an authorized, structured, ongoing review of practitioner prescribing, pharmacist dispensing, and patient use of medications. The purpose of a DUE is to ensure that drugs are used appropriately, safely, and effectively to improve patient health status. In addition, continual improvement in the appropriate and effective use of drugs has the potential to lower the overall cost of care.3, 4, 7 DUE allows the pharmacist to document and substantiate the benefit of pharmacy intervention in improving therapeutic and economic outcomes.3

DUE is typically classified in three different categories: prospective, concurrent, and retrospective.

Prospective DUE: Prospective review involves evaluating a patient's planned drug therapy before a medication is dispensed. This process allows the pharmacist to identify and resolve problems before the patient has received the medication. Pharmacists routinely perform prospective reviews in their daily practice by assessing a prescription medication's dosage and directions and reviewing patient information for possible drug interactions or duplicate therapy.

Issues Commonly Addressed by Prospective DUE5 :

Drug-disease contraindications

Therapeutic interchange

Generic substitution

Incorrect drug dosage

Inappropriate duration of drug treatment

Drug-allergy interactions

Clinical abuse/misuse

Example: Identification of drug-drug interactions are a common outcome of a prospective DUE. For example, a patient being treated with warfarin to prevent blood clots may be prescribed a new drug by another specialist to treat arthritis. If taken together, the patient could experience internal bleeding. Upon reviewing the patient's prescriptions, the pharmacist notes the potential drug interaction and contacts the prescriber to alert him/her to the problem.

Concurrent DUE: Concurrent review is performed during the course of treatment and involves the ongoing monitoring of drug therapy to ensure positive patient outcomes. Some refer to this as case management or health management. It presents pharmacists with the opportunity to alert prescribers to potential problems and to intervene in areas such as drug-drug interactions, duplicate therapy, over or underutilization, and excessive or insufficient dosing. This type of review allows therapy for a patient to be altered if necessary.

Issues Commonly addressed by Concurrent DUE5 :

Example: Concurrent DUE often occurs in institutional settings. Patients in these settings often receive multiple medications. Periodic review of patient records can detect actual or potential drug-drug interactions or duplicate therapy. This type of review can also alert the pharmacist to the need for changes in medications such as antibiotics or the need for dosage adjustments based on laboratory test results. The key physician(s) must then be alerted to the situation so that corrective action can be taken.

Retrospective DUE: A retrospective DUE is the simplest to perform since drug therapy is reviewed after the patient has received the medication. A retrospective review may detect patterns in prescribing, dispensing, or administering drugs to prevent recurrence of inappropriate use or abuse and serves as a means for developing prospective standards and target interventions. In retrospective DUE, patient medical charts or computerized records are screened to determine whether the drug therapy met approved criteria and aids prescribers in improving care for their patients, individually and within groups of patients, such as those with diabetes, asthma, or high blood pressure.

Issues Commonly Addressed by Retrospective DUE5:

Example: An example of a retrospective DUE may be identification of a group of patients whose therapy does not meet approved guidelines.2 Upon retrospective review the pharmacist may identify a group of patients with asthma who, according to their medical and pharmacy history, should be using orally inhaled steroids. Using this information, the pharmacist can then encourage physicians to prescribe the indicated drugs.

Steps in Conducting a Drug Use Evaluation

Most authors agree that the following five steps are essential when conducting any quality-related DUE program: 3,4

  1. Identify or Determine Optimal Use - Criteria are defined to allow for comparisons of optimal use with actual use. Criteria should focus on relevant outcomes. For example, if the use of a drug prescribed to treat a patient with diabetes is being evaluated, then set standards should be determined to evaluate its effectiveness, such as a decrease in blood glucose or HbA1c (glycosylated hemoglobin) levels.
  2. Measure Actual Use - This step is where data is gathered to measure the actual use of medications. This data can be obtained from medical and prescription records or electronic claim forms.
  3. Compare - This involves the comparison between optimal or appropriate and actual use. During this process, the evaluator determines whether findings are expected and causes for any discrepancies. In this process, patterns or aberrations can be interpreted.
  4. Intervene - This is the step where corrective action is implemented. Action should be targeted to areas of concern such as prescribing patterns, medication misadventures, the quality of drug therapy, or economic consideration.
  5. Evaluate the DUE Program - The last step is to assess the effectiveness of the DUE program. Efforts should be made to evaluate the outcomes and document reasons for positive and negative results. Implementing appropriate changes to the DUE program and continued observation should be undertaken.

Value of DUE Programs

Managed health care systems and pharmacy benefit management companies (PBMs) have the responsibility of managing the medication use of anywhere from a few hundred thousand to millions of patients. DUE programs play a key role in helping these organizations understand, interpret, and improve the prescribing, administration, and use of medications. This is often accomplished by using DUE programs to provide physicians with feedback on their performance and prescribing behaviors as compared to pre-set criteria or treatment protocols.

DUE information also allows physicians to compare their approach to treating certain diseases with their peers. The "peer pressure" generated by these comparisons is useful in stimulating physicians to change their prescribing habits in an effort to improve care. For example, many health plans use DUE to encourage physicians to use more generic drugs and to comply with treatment guidelines established by national organizations such as the National Institutes of Health or the American Heart Association.

DUE information also assists managed health care systems and PBMs in designing educational programs that improve rational prescribing, formulary compliance, and patient compliance. These educational programs may take the form of face-to-face education of physicians and patients by clinical pharmacists, telephone calls, letters, newsletters, and educational symposia.

Role of the Pharmacist

Prospective DUE: The pharmacist plays a key role in the prospective DUE process because of his/her expertise in the area of pharmaceutical care. The prospective DUE process places responsibility on the pharmacist to conduct a review of the drug order when it is presented for filling and proactively resolve potential drug-patient problems. This process affords the pharmacist the opportunity to interact with patients and members of the health care team to work on a treatment plan for each patient. In the retail and institutional settings, the pharmacist can assess the prescription order at the time of dispensing and, using information from the patient's medical and/or pharmacy record, determine the appropriateness of the drug therapy prescribed. If the pharmacist identifies opportunities for improved patient care, he/she can contact the prescriber to discuss treatment alternatives.

Concurrent DUE: The pharmacist has the responsibility, in the concurrent DUE process, to assess the ongoing therapy of the patient and intervene, when necessary, to help modify the patient's treatment plan. When caring for those patients with multiple diseases, the pharmacist can support the role of case managers and become actively involved in the management of the patient's condition. Through interaction with the prescriber, he/she can better understand the care plan the prescriber would like to follow. Through patient counseling, the pharmacist can offer education on the proper use of the medication and can determine if there are specific patient needs.

Retrospective DUE: Because of their expertise in drug therapy management, pharmacists play a leading role in describing the relationship between drug use and patient outcomes using retrospective DUE. When addressing population-based retrospective DUE issues rather than individual patient care, the managed care pharmacist has a primary role in planning, organizing, and implementing DUE activities. Pharmacists can educate health care practitioners regarding drug use, participate in decision making within the context of the Pharmacy & Therapeutics Committee, and serve as members of DUE and other committees where input concerning drug use and drug policy development is required.6

Conclusion The process of DUE is still evolving. Using DUE information, managed care pharmacists can identify prescribing trends in patient populations and initiate corrective action to improve drug therapy for groups of patients, as well as individuals. As the variety of health care professionals (pharmacists, physicians, nurses, optometrists, naturopaths, chiropractors) involved in the medication use process expands, DUE will require a more multidisciplinary approach to improving patient care. In addition, rapidly improving data systems will soon provide the methodology for marrying medical and pharmacy data with patient outcome data. This will lead to the next logical step, the evolution of DUE into a more comprehensive "healthcare utilization evaluation." 8

REFERENCES

1. Joint Commission on the Accreditation of Healthcare Organizations. 1995 comprehensive accreditation manual for hospitals. Oakbrook Terrace (IL): Joint Commission on the Accreditation of Healthcare Organizations; 1994.

2. Kubacka RT. A primer on drug utilization review. J Am Pharm Assoc 1996;NS(4):257-61.

3. Palumbo FB, Ober J. Drug use evaluation. In: Principles and practices of managed care pharmacy. Alexandria (VA): Academy of Managed Care Pharmacy; 1995. p. 51-60.

4. Yates WN, Rupp MT, Schondelmeyer SW. A drug utilization evaluation primer: conceptual and operational aspects. Proceedings of the Group Health Association of America, Annual Meeting; 1991 Jun 25; New York.

5. APhA special report. Opportunities for the community pharmacist in managed care. Washington: American Pharmaceutical Association; 1994.

6. American Society of Health System Pharmacists. ASHP statement on the pharmacist's clinical role in organized healthcare settings. Am J Hosp Pharm 1989;46:805-6.

7. Academy of Managed Care Pharmacy. Concepts in Managed Care Pharmacy Series ñ Pharmaceutical Care. 1997.

8. Bowman L. Drug use evaluation is DUE: Healthcare utilization evaluation is over-DUE. Hosp Pharm. 1996; 31:347-53.

 



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Stanley S. Weber, Pharm.D, FASHP, BCPP
Director, Joint Doctor of Pharmacy Degree Program
University of Washington and Washington State University
Copyright © 1997-9
Comments: expharmd@u.washington.edu
Revised: November 9, 1999