1. Drug Utilization Review & Drug Utilization Evaluation: An Overview
Presentation Developed for the Academy of Managed Care Pharmacy
Updated: February 2016

2. Learning Objectives
Differentiate between the terms Drug Utilization Review (DUR) and Drug Utilization Evaluation (DUE)
Explain the role of a pharmacist in a DUR program
Provide an example for each of the three types of DUR’s: 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): An authorized, structured, ongoing review of health care provider prescribing, pharmacist dispensing, and patient use of medication.
Drug Utilization Evaluation (DUE): A qualitative evaluation of drug use, prescribing, and member fill patterns to determine the appropriateness of drug therapy.
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.
AMCP. Glossary of Managed Care Terms.

4. Goals of DUR and DUE
Improve quality of care and overall drug effectiveness
Prevent adverse drug reactions
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
Drug-drug and drug-disease interactions
Dosing appropriateness
Drug-patient precautions (due to age, allergies, gender, pregnancy, etc.)
Medication directions
Formulary substitutions (e.g., therapeutic interchange, generic substitution)
Inappropriate duration of drug treatment
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 medications dosage and directions while reviewing patient information for possible drug interactions or duplicate therapy. Upon reviewing the patient's prescriptions, the pharmacist would note the potential drug interaction and contact the prescriber to alert him/her to the problem.
Example: Identification of drug-drug interactions are a common outcome of a prospective DUR. 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.
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
Over or underutilization of medication
Excessive or insufficient dosing
Drug-drug interactions
Drug-disease interactions
Drug dosage modifications
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.
Example: Concurrent DUR often occurs in institutional settings, where patients often receive multiple medications. Periodic review of patient records can detect actual or potential drug-drug interactions or duplicate therapy. It 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 prescriber(s) must then be alerted to the situation so corrective action can be taken.
AMCP. Glossary of Managed Care Terms.

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
Quality assurance analyses
Developing standard guidelines to achieve target outcomes at a population level
Appropriate generic use
Use of formulary medications whenever appropriate
Therapeutic appropriateness and/or duplication
Ties to drug utilization evaluation for identifying trends and adapting approval criteria based on evaluation of the impact of such criteria on drug use.
Example: An example of a retrospective DUR may be the identification of a group of patients whose therapy does not meet approved guidelines. For example, a 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 prescribers to utilize the indicated drugs.
AMCP. Glossary of Managed Care Terms.

10. The DUR Process Determine criteria Collect data
The criteria should focus on relevant outcomes within a delineated scope for DUR and identify the relevant drugs to be monitored for optimal use
Collect data
Measure the actual use of medications
Compare the data to established criteria
Involves applying the algorithm, identifying members who meet the DUR criteria and the comparison between optimal or appropriate and actual use
Perform intervention
Action should be targeted to areas of concern such as prescribing patterns, medication misadventures, and quality of drug therapy or economic consideration.

11. The DUR Process Analyze results Document DUR
Evaluate the outcomes and document reasons for positive and negative results
Document DUR
Report the findings to the appropriate team within the organization (e.g., the pharmacy & therapeutics committee) and/or individual prescribers when appropriate
Re-evaluate the program (on-going)

12. 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.

13. Example
"This asthma is really slowing me down.  This prescription isn't helping much."
Example Scenario: Tim's asthma is not well controlled, and he uses his inhaler multiple times a day.  Tim's therapy should most likely be increased to prevent further medical complications.
Pharmacist Interaction: A pharmacist conducted concurrent DUR at the health plan and noticed that Tim was only prescribed an as-needed inhaler.  With the pharmacist's recommendation to the prescriber, derived from evidence-based guidelines, Tim was prescribed a maintenance asthma medication.
Benefit: Although another medication was added, the patient and the health plan have an overall cost savings.  The added prescription vastly decreases Tim's likelihood of a costly emergency room visit for a severe asthma attack and enhances Tim's quality of life.

14. 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

15. Thank you to AMCP member Alvah Stahlnecker for updating this presentation for 2016.