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

2. 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

3. 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.
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.

4. 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.

5. 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

6. 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.

7. 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.

8. 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.
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.

9. 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.
Ties to drug utilization evaluation for identifying trends and adapting approval criteria based on evaluation of the impact of such criteria on drug use.

10. 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)

11. 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.

12. 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

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