Drug Utilization Review & Drug Utilization Evaluation: An Overview Presentation Developed for the Academy of Managed Care Pharmacy Updated: February 2013

Learning Objectives Differentiate between the terms drug utilization review and drug utilization evaluation Explain the role of a pharmacist in a drug utilization review program Provide an example for each of the three types of drug utilization reviews: prospective, concurrent, and retrospective Describe the key stakeholders vested in a successful DUR/DUE program

Definition of DUR and DUE Drug Utilization Review (DUR): A systematic, ongoing review of prescribing, dispensing, and member drug fills to detect and manage preventable drug-related issues related to cost, safety, and/or efficacy Drug Utilization Evaluation (DUE): A qualitative evaluation of drug use, prescribing, and member fill patterns to determine the appropriateness of drug therapy AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary DUR: Also referred to as medication use management; Cost – is the member using the most appropriate, least costly medication? Is adherence affected if the patient cannot afford the medication? Safety – is the member using a medication or does the member have a condition that interacts with the newly requested medication? Does the member have a gene that predisposes him/her to a particular fatal reaction/response? Safety considerations also include abuse/misuse. Efficacy – is the member using the most effective drug combination? most effective, least costly medication? Does the member have a gene that ensures a positive response to the treatment? DUE: Also referred to as medication use evaluation (MUE). Evaluation of drug use over time which often requires a multidisciplinary effort.

Goals of DUR and DUE Improve quality of care Encourage the practice of evidence-based, clinically appropriate, cost-effective drug use Reduce drug misuse and abuse Reduce costs related to inappropriate drug use DUR and DUE are quality assurance methods that are viewed as such by accrediting and quality assuring bodies such as the Joint Commission on Accreditation of Health Care Organizations (JCAHO) for hospitals and National Committee for Quality Assurance (NCQA) for health plans, for example.

Pharmacist Role in DUR & DUE Identifies opportunities for quality improvement Participates in efforts to improve: Patient outcomes Quality of programs Promotes appropriate drug use to reduce overall health care costs and improve access to care Carries out ethical and professional responsibility

A Model DUR Program Access to member drug utilization data Qualified pharmacists with authority to review Knowledge of population served and delivery system Availability of established standards for comparison Measurement of utilization review outcomes The DUR model originated in 1976 and its proposed structure is still used today. Now, the greatest emphasis in DUR program design is that DUR programs are “ongoing” or “continuous” which requires perpetual evaluation, communication, and adaptation through corrective actions to ensure a quality program.

Prospective DUR A screening method by which a health care provider reviews the necessity of drug therapy before it is dispensed or administered Electronic DUE programs at retail pharmacies Prior authorization (PA) programs AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary

Concurrent DUR A screening method by which a health care provider reviews the necessity of drug therapy at the time of dispensing or during treatment Case management Review of patient records Research projects that follow patients in randomized, controlled trials Real-time system edits at the point of service AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary Concurrent DUR is typically conducted jointly by a direct care/care coordination provider and a non-care provider (ex: nurse case manager and dispensing pharmacist). Some authors view “point-of-sale” edits as concurrent DUR. Examples include: drug interaction, drug allergy, inappropriate dose, and duplicate therapy alerts.

Retrospective DUR A screening method by which a health care provider reviews the necessity of drug therapy after it has been dispensed or treatment has started Review of medical charts, electronic medical records and/or claims data to assess appropriate drug use Review provider prescribing patterns AMCP. Glossary of Managed Care Terms. http://www.amcp.org/amcp.ark?c=pr&sc=glossary Ties to drug utilization evaluation for identifying trends and adapting approval criteria based on evaluation of the impact of such criteria on drug use.

The DUR Process Determine criteria Collect data Compare the data to established criteria Perform intervention Analyze results Document DUR Re-evaluate the program (on-going)

Who Benefits from DUE/DUR? Accrediting bodies/Government National Committee for Quality Assurance Joint Commission on Accreditation of Healthcare Organizations Omnibus Budget Reconciliation Act 1990 Plan member Health care provider Pharmacist Health care system OBRA 90 required DUR services for ambulatory services for Medicaid patients. NCQA and JCAHO assure consistent delivery of quality programs – stamp of approval Member – receives most appropriate therapy HC Provider – improved quality care for their patients; knowledge of how they compare to fellow providers and someone there to assure quality; unbiased education on standards of care/practice delivery Pharmacist – supports DUR activities on the bench esp for pharmacists who struggle to do a better job at this Health care system – better control of drug costs– greatest contributor to expenditure on health care in the nation.

Conclusion A pharmacist performs DUR/DUE to improve overall access and quality of care, and to reduce costs Each type of DUR represents an important step in ensuring that the member receives the most appropriate, cost-effective medication A successful DUR/DUE program benefits all health care players, including the member

Thank you to AMCP member Jennifer Wilbanks for updating this presentation for 2013